1. 2017
@NatCOPDAudit #COPDAuditQI

2. Secondary care audit - context
The audit moved to continuous data collection on 1 February 2017.
There have been four run charts released: best practice tariff indicators, spirometry, oxygen, and smoking.
NIV and readmissions to come
The Best Practice Tariff for COPD began on 1 April 2017.
Over 40,000 cases have been entered onto the web-tool so far.
@NatCOPDAudit #COPDAuditQI

3. Secondary care audit – 2014 findings
Reduction in inpatient mortality (7.9% 2003, 7.8% 2008, 4.3% 2014).
Reduction in length of stay (6 days 2003, 5 days 2008, 4 days 2014).
Variation in the delivery of specialist care, as well as access to spirometry results, smoking cessation services, and pulmonary rehabilitation.
COPD admissions have risen 13% between 2008 and 2014.
Only 46% of patients were seen by a member of the respiratory team within 24 hours.
@NatCOPDAudit #COPDAuditQI

4. Workshop aims – part 1 @NatCOPDAudit #COPDAuditQI
Understanding your data and service – reflecting on your own service and data to identify areas for change.
Familiarisation with selected QI methodologies and techniques - understanding basic principles of QI as shown in the Model for Improvement
Taster/starting to have identified priority areas for improvement
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5. Workshop aims – part 2 @NatCOPDAudit #COPDAuditQI
Taster of setting aim, and breaking down the problem using driver diagram
Taster of planning small test of change
To network with colleagues to share expertise and examples of best practice
To leave the workshop with an action plan to implement and evaluate improvement in your service.
@NatCOPDAudit #COPDAuditQI

6. Housekeeping
Toilets
Lunch and refreshments
No planned fire alarms
Emergency exits
There will be feedback forms for completion at the end of the day
Please visit the resource table
and
event hashtag is #COPDAuditQI
@NatCOPDAudit #COPDAuditQI

7. Ice breaker
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8. Ice breaker
As a table (not solely with your own team) please discuss the following:
One recent success from your local COPD service or hospital
One challenge you have recently faced as a COPD service.
Please put them on a Post It note and place on the board
@NatCOPDAudit #COPDAuditQI

9. What does your data show you and how can you effect change?
Brief overview of the quality journey
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10. Data collection Importance of good data collection in supporting QI
Good data collection might involve:
Sharing data entry with colleagues – for example a rota
Dedicated staff member for entering data
Working with the information and coding departments to receive notes in a timely fashion, and check all eligible patients are included
Completing audit questions during the patient’s admission, rather than after
See the National COPD Audit Programme’s Good Practice Repository for more ideas and tips.
@NatCOPDAudit #COPDAuditQI

11. Intervention and impact
Phases of a quality improvement project
Model for improvement
Project setup
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act
Plan Do
Study
Diagnostic phase
Intervention and impact
Sustain and spread
@NatCOPDAudit #COPDAuditQI

12. Project set up Specific S Measurable M Achievable A Realistic R
Build a team and understand your stakeholders
Who might help or hinder? What do your patients want?
Agree your aim – make it SMART
Consider ways of tackling a problem
Driver diagrams
Plan how you will achieve your aim
What measures will show you are improving? S
Specific M
Measurable A
Achievable R
Realistic T
Time bound
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13. Diagnostic phase
Stakeholder views of quality and priorities for improvement
What does your current audit data tell you?
Understanding your processes
Process mapping
Think about why you might have certain issues
Root cause analysis
Breaking down the problem, and identifying tests of change
@NatCOPDAudit #COPDAuditQI

14. What’s the problem? Respiratory review
To meet the COPD BPT, the following metrics must be met:
60% of patients receiving respiratory review within 24 hours of admission; and:
60% of patients receiving a discharge bundle
Data in the first quarter shows that only 50% of patients are getting timely respiratory review
Problem? No BPT for the hospital!
@NatCOPDAudit #COPDAuditQI

15. Process mapping – respiratory review
A&E
consultant
review
Arrival
@ A&E
Triage
Acute
medicine
review
Patient
admitted
Treatment
decisions
Referral to
resp
Bloods
Imaging
PAS
Bottle necks
Duplication
Unclear process
Clarity of roles
@NatCOPDAudit #COPDAuditQI

16. Process mapping – in real life!
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17. Driver Diagrams @NatCOPDAudit #COPDAuditQI Aims Primary drivers
Secondary drivers
To increase the number of patients receiving a respiratory review within 24 hours from 50% to 60% by the end of the next quarter (end of December 2017)
Rapid and appropriate diagnostic testing in A&E
Improve systems for referral across teams (including treatment induced referral)
Up-skill all members of respiratory team to provide review
Increase frequency of respiratory rounds
Design concise guideline on appropriate tests
Make sure ED and AAU team have bleep numbers of on call respiratory specialist team member
Training session on discharge bundle and best practice 
Ensure there is an early morning referral round 6 days a week
@NatCOPDAudit #COPDAuditQI

18. How will we know that change is an improvement
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19. How will we know that change is an improvement
Unit 1
Unit 3
Unit 2
Length of stay results for units 1, 2 and 3
References for Measurement for Improvement:
Improvement capability games – video resources from IHI
Perla RJ et al. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Qual Saf 2011;20:46e51
@NatCOPDAudit #COPDAuditQI

20. Implement Model for improvement Act Plan Study Do
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act
Plan Do
Study
@NatCOPDAudit #COPDAuditQI

21. What is the PDSA Cycle? @NatCOPDAudit #COPDAuditQI 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) Do
Carry out the plan
Document problems and unexpected observations
Begin analysis of the data
Study
Complete the analysis of the data
Compare data to predictions
Summarise what was learned
To test changes, we use PDSA, which uses the same three questions with each change that we test:
What are we trying to accomplish? (Objective in plan)
How will we know that a change is an improvement? (verbal or numerative feedback conducted during PDSA
What changes can we make that will result in improvement? (after study, will act to implement or plan another PDSA)
@NatCOPDAudit #COPDAuditQI

22. Why test changes?
To increase the belief that the change will result in improvements in your setting
To learn how to adapt the change to conditions in your setting
To evaluate the costs and ‘side-effects’ of changes
To minimize resistance when spreading the change throughout the organization
@NatCOPDAudit #COPDAuditQI

23. Move quickly to testing changes
Year Quarter Month Week Day Hour
‘What tests can we complete by next Tuesday?’
“If you think we can test the change in a month, what can you test a day from now?”
Assumptions about Time: 2 Orders of Magnitude LESS
teams are most effective when they move quickly to testing changes (& maintain momentum)
best to first test innovative changes on a small scale
okay to test multiple changes at once
test under a variety of conditions
importance of linking tests of change
don’t try to get buy-in or consensus for tests (but will be necessary for implementation)
@NatCOPDAudit #COPDAuditQI

24. LEARN: Repeated Use of the Cycle
Changes that result in improvement A P S D
DATA D S P A A P S D A P S D
Hunches Theories Ideas
@NatCOPDAudit #COPDAuditQI

25. Examples of PDSA Cycles
Increased number of patients reviewed within 24 hours A P S D
Data
Cycle 1: laminated poster with respiratory contact details placed in ED and admission ward
Cycle 2: Instigate 2 x respiratory rounds of A&E per day
Cycle 3: Education event provided to ED and admission staff
Cycle 4: Instant alert for known COPD
patients to respiratory team on arrival
Not enough patients being seen by a member of the respiratory team in 24 hours
@NatCOPDAudit #COPDAuditQI

26. Measuring change @NatCOPDAudit #COPDAuditQI Cycle 4 Cycle 2 Cycle 3

27. SUSTAIN and SPREAD Test with larger group Adapt your methods
Link with other organisational drivers
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28. Coffee break
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29. Identifying a key priority for change in your COPD service and generating an improvement aim
All attendees (group work, based on preparatory work done prior to event)
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30. Identifying a key priority for change
Table shuffle (into themed groups)
Packs have been provided to each attending team
Aim development should focus on SMART objectives
Look for areas where you can realistically make improvements S
Specific M
Measurable A
Achievable R
Realistic T
Time bound
@NatCOPDAudit #COPDAuditQI

31. Identifying a key priority for change
Not ‘we aim to improve our specialist review time’, but:
‘We aim to improve the number of patients receiving a discharge bundle from 60% to 70% within 3 months’
Use your run charts
Use your exports
What can you do?
Where do you want to be?
Once you have decided on your aim, please write it on your A3 driver diagram.
@NatCOPDAudit #COPDAuditQI

32. Lunch
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33. Breaking down the issues, and identifying the first area for change
Using driver diagrams
All attendees
@NatCOPDAudit #COPDAuditQI

34. Breaking down the issues
Using driver diagrams
@NatCOPDAudit #COPDAuditQI

35. Coffee break

36. Review of the model for improvement
@NatCOPDAudit #COPDAuditQI

37. Implement Model for improvement Act Plan Study Do
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Act
Plan Do
Study
@NatCOPDAudit #COPDAuditQI

38. What is the PDSA Cycle? @NatCOPDAudit #COPDAuditQI 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) Do
Carry out the plan
Document problems and unexpected observations
Begin analysis of the data
Study
Complete the analysis of the data
Compare data to predictions
Summarise what was learned
To test changes, we use PDSA, which uses the same three questions with each change that we test:
What are we trying to accomplish? (Objective in plan)
How will we know that a change is an improvement? (verbal or numerative feedback conducted during PDSA
What changes can we make that will result in improvement? (after study, will act to implement or plan another PDSA)
@NatCOPDAudit #COPDAuditQI

39. LEARN: repeated use of the cycle
Changes That Result in Improvement A P S D
DATA D S P A A P S D A P S D
Hunches Theories Ideas
@NatCOPDAudit #COPDAuditQI

40. Planning your first test of change
@NatCOPDAudit #COPDAuditQI

41. Planning your first test of change
@NatCOPDAudit #COPDAuditQI

42. Feedback, sharing of best-practice, discussion and questions
@NatCOPDAudit #COPDAuditQI

43. What do we need to do when we get back?
@NatCOPDAudit #COPDAuditQI

44. Thoughts on next steps Identify a team Think about your stakeholders
Process map your pathways
Identify priorities
Review your aim
Start to plan your measures
Agree a plan- each element underpinned by PDSA test cycles- in small bites!
@NatCOPDAudit #COPDAuditQI

45. Your team Clinical leader Technical expert Day to day leader
Additional team members
Ideally:
Project sponsor
Institute for Healthcare Improvement: Science of improvement (
Clinical leader: Overall lead for project, probably senior within organisation
Technical expert: This may be patients, frontline staff, IT etc
Day to day leader
Additional team members: This may be managers, finance, or others who might not work through whole project
Ideally
Project sponsor: someone senior, maybe trust board member who can support and facilitate the changes and help you overcome any potential organisational barriers
@NatCOPDAudit #COPDAuditQI

46. Stakeholders Who might need to know about your work?
Who could support and influence the outcome?
Who might stop/ stall the outcome?
How will you involve patients/ carers?
@NatCOPDAudit #COPDAuditQI

47. Plan your project
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48. @NatCOPDAudit #COPDAuditQI

49. Other resources
QI Hub
Developing a patient and public involvement panel for quality improvement, HQIP
The Handbook of Quality and Service Improvement Tools, NHS Institute for Innovation and Improvement (Now archived LIBRARY)
Quality Improvement Essentials Toolkit, IHI
@NatCOPDAudit #COPDAuditQI

50. Plans for future activity and concluding remarks
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51. Plans for future activity and concluding remarks
Collaboratives
Appetite for a QI webinar
Following up
The audit team will be in touch in the next three months to ask how your improvement is going
Feedback forms
Please complete them to help us improve!
@NatCOPDAudit #COPDAuditQI

52. Networking, further questions, and close
@NatCOPDAudit #COPDAuditQI