1. Supporting Improvement in nutritional care across nhs scotland
Quality Improvement
Supporting Improvement in nutritional care across nhs scotland
Jane Murkin
Associate Director of Improvement

2. Session aims
Context of healthcare today and its relationship with quality improvement
Increase understanding and application of improvement science and methodologies in relation to improving nutritional care
Building capacity and capability in quality improvement
Learning from others - collaboration – a nutritional care network and community
Supporting the spread and dissemination of best practice
Plan the testing and implementation of ideas and changes
An exciting opportunity to actively participate in implementation of improvements in nutritional care across NHS Scotland

3. Lets take a moment to…… Thank you and celebrate your successes
Building on work to date – acknowledge the need to focus on demonstrable measurement for improvement
Quality strategy
Focus – what have we achieved, where are our gaps ,next steps, priority areas for spreading the testing and implementation
Developing your spread and implementation plans
Achieving reliability

4. Care is not safe – Institute of Medicine report
“Between the care we have
and the care we could have,
lies not a gap, but a chasm”

5. How many people are
harmed in
our healthcare system?

6. Adverse Events in Hospital
3.7% Harvard 1991
16.6% Australia 1995
10.8% London % PREVENTABLE
3 million bed days in UK
£1 billion per annum in UK
Acute hospitals 9.5% - HAI
(July 2007 HPS)
Pre work SPSP
SPSP Data – what are we learning in relation to harm

7. A Major Study of Reliability in American Health Care…
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: (June 26, 2003)
439 indicators of clinical quality of care
30 acute and chronic conditions
Medical records for 6712 patients
Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic 56.1%; Preventative 54.9%)
Conclusion: The Defect Rate in technical quality of American health care is approximately
45%

8. How safe are clinical systems?
Primary research into the reliability of systems within 7 NHS organisations and ideas for improvement ( Health Foundation May 2010) Reliability in healthcare – This is not simply a matter of putting in place proper guidelines and expecting practitioners to follow them. It involves identifying in advance the points at which those mistakes can happen, the different elements that contribute to those mistakes and the systems that practitioners should follow in order to ensure pt safety

9. Converting research to care
Publication
Bibliographic databases
Submission
Reviews, guidelines, textbook
Negative results
variable
0.3 year
years
50%
46%
18%
35%
0.6 year
0.5 year
9.3 years
Dickersin, 1987
Koren, 1989
Balas, 1995
Poynard, 1985
Kumar, 1992
Poyer, 1982
Antman, 1992
Lack of numbers
Expert
opinion
Inconsistent
indexing
17:14
Original research
Acceptance
Patient Care
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
17 years to apply 14% of research knowledge
to patient care! 9

10. Mid Staffordshire report
Brings me on to, “we have 2 jobs to do 10

11. 11

14. Remember…

15. Develop the Quality Improvement Hub, reflecting a new partnership for improvement between NHS National Services Scotland (NSS), NHS Quality improvement Scotland (QIS), NHS Heath Scotland, NHS National Education for Scotland (NES), and the Scottish Government Health Directorates Improvement and Support Team (IST).
Scottish Government, May 2010

16. The NHS Scotland Quality Improvement Hub works in partnership by providing a coordinated national resource to care teams and organisations.
Providing :
Implementation support which is flexible and responsive
Education and learning about QI which is accessible and relevant
Measurement of QI which is meaningful
Facilitating QI networks for NHS staff

17. Models for change Model for Improvement - Today's focus Reliability
Demand and capacity
Process mapping / Value stream
Lean
Six-sigma

18. Changing systems Change is difficult and can be threatening
Change can be time-consuming
Change involves understanding people, systems and processes
Healthcare systems are often complex and fragmented

19. What is improvement?
Its about developing care that delivers for patients.
Its about breaking the
"We've always done it like this!"
culture, encouraging both patients and staff to challenge and change healthcare services for the better.

20. The Quality Pioneers Walter Shewhart (1891 – 1967) W. Edwards Deming
( )
Joseph Juran
( ) 20

21. History Originally known as Shewart cycle for improvement – 1920s
Deming cycle – 1950s
Engineering - PDCA
Known as PDSA in healthcare

22. Subject Matter Knowledge
Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge.
Improvement
Subject Matter Knowledge
Profound Knowledge
Profound Knowledge: The interaction of the theories of systems, variation, knowledge, and psychology.
(W Edwards Deming) 22

23. QI The Primary Drivers of Improvement
Having the Will (desire) to change the current state to one that is better
Will
Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas
Developing Ideas that will contribute to making processes and outcome better QI
Ideas
Execution

24. The Quality Measurement Journey
AIM (Why are you measuring?)
Concept
Measure
Operational Definitions
Data Collection Plan
Data Collection
Analysis
ACTION
Source: Lloyd, R. Quality Health Care. Jones and Bartlett Publishers, Inc., 2004: 24 24

25. Is there an end in site to this measurement stuff?

26. A Model for Learning and Change
When you combine the 3 questions with the…
…the Model for Improvement.
PDSA cycle, you get…
The Improvement Guide, API, 2009. 26

27. The basics Aims Measures Changes Testing
What are yours in relation to improving nutritional care? 27

28. The Improvement Guide, API28

29. Aims create systems
“Set the Table”

30. Set the dinner table for 6 people by 6pm

31. Aims Aligned Timed Numeric Unachievable (by hard work alone)
Non-negotiable (once set) 31

32. Developing an Aim Statement
Team name:
Aim statement
(What’s the problem? Why is it important? What are we going to do about it?)
You should review your Aim Statement frequently to make sure it is consistent and that everyone involved with the initiative has a common understanding of what is to achieved.
How good?
By when? 32

33. How good? By When? Hope is not a plan! Example #1 of an Aim Statement
Overall, to reduce number of patients admitted to hospital with malnutrition by 50% within 2 years.
How good? By When?
Be flexible in format. People have preferences. Key is getting a focus statement. Remember that we use the AIM as singular, even if there are multiple objectives for cycles and measures, etc.
Very important to keep focus for a year.
Hope is not a plan! 33

34. What do you think of these Aim Statements?
We aim to reduce harm and improve patient safety for all of our patients.
By June of 2010 we will reduce the incidence of pressure ulcers in the critical care unit by 50%.
Our patient satisfaction scores are in the bottom 10% of the national comparative database we use. As directed by senior management, we need to get the score above the 50th percentile by the end of the 2st Q of 2010.
We will prevent patients becoming malnourished.
Our most recent data reveal that on the average we only reconcile the medications of 35% of our discharged inpatients. We intend to increase this average to 50% by 4/1/10 and to 75% by 8/31/10. 34

35. Aim Statements
Achieve 100% compliance with appropriate selection and timing of prophylactic antibiotic administration in 3 months
Reduce Central Line Infections in the ICU by 75 percent within 11 months
95% of COPD patients on ward 6 assessed by MUST screening tool on admission
95% of patients discharged to nursing homes from ward 1 with a diet plan 35

36. Measures

37. The Improvement Guide, API37

38. Stages of Facing Data Reality
“The data are wrong”
“The data are right, but it’s not a problem”
“The data are right; it is a problem; but it is not my problem.”
“I accept the burden of improvement, but I have no idea how to get there!”
Adapted from D. Berwick and B. Jarman, 2005. 38

39. How Do We Know if a Change is an improvement?
“You can’t fatten a cow by weighing it”
- Palestinian Proverb
Improvement is NOT about measurement
However… 39 39

40. The Three Faces of Performance Measurement
Aspect
Improvement
Accountability
Research
Aim
Improvement of care
Comparison, choice, reassurance, spur for change
New knowledge
Methods:
Test Observability
Test observable
No test, evaluate current performance
Test blinded or controlled
Bias
Accept consistent bias
Measure 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 hypothesis
Fixed hypothesis
Testing Strategy
Sequential tests
No tests
One large test
Determining if a
change is an
improvement
Run charts or Shewhart control charts
No change focus
Hypothesis, statistical tests (t-test, F-test, chi square), p-values
Confidentiality of
the data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
Lief Solberg, Gordon Mosser and Sharon McDonald Journal on Quality Improvement vol. 23, no. 3, (March 1997),

41. “When you have two data points, it is very likely that one will be different from the other.”
W. Edwards Deming
R Lloyd, Institute for Healthcare Improvement 41

42. 42

43. Unit 2 Unit 1 Unit 3 Cycle time results for units 1, 2 and 3
R Lloyd, Institute for Healthcare Improvement 43

44. Sometimes gathering data can bring new and surprising knowledge!

45. And sometimes you discover that the data you are analysing do not match your view of reality!

46. Why Do You Need Data and Information?
To plan for improvement
For testing change
For tracking compliance
For determining outcomes
For monitoring long term progress
To tell their story 46

47. Three Types of Measures
Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result?
Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?
Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)?
When measuring for improvement we may have measures that are outcome, process or balancing.
Outcome measures are…they are a must have. If our collaborative does not have outcome measures it is difficult to justify the time/expense. How will we convince anyone that we made a difference to the pt/customer??
Process- Early indicators of improvement…logically connected to outcome….easy to overdo the # of process measures.
Balancing: optional but wise to have one or two. 47 2

48. Measurement Guidelines
The question - How will we know that a change is an improvement? - usually requires more than one measure
A balanced set of five to eight measures will ensure that the system is improved
Balancing measures are needed to assess whether the system as a whole is being improved

49. Changes

50. The Improvement Guide, API

51. 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

52. PDSA Worksheet

53. Exercise – Paper aeroplanes

55. 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

56. Improvement Measurement Journey
AIM – Improved nutritional care
Concept – Prevent malnutrition in frail elderly patients
Measure – % compliance with MUST screening tool
Operational Definition – N: total number of opportunities in the sample where MUST screening tool was used on admission for frail elderly patients divided by D: total number of opportunities in the sample multiplied by 100 = % Compliance
Data Collection Plan – monthly
Data Collection – unit submits data for analysis to area/dept collating data
Analysis – Run or Control chart
Tests of Change

57. Local Display and Feedback of Data

58. Don’t Loose Site The data are our patients
Make sure your data tells the story and the context
Remind your colleagues its easy to forget!
Patient stories
Patient involvement in your improvement work
Person centeredness
Experience based design

59. What will it take to improve quality ?
Winning the hearts and minds of the staff
Focusing on improvement not targets
Leadership
Integration
Making it daily work
Creating infrastructure
Creating capability and capacity
Measurement that has meaning
Understanding context and culture
Momentum

60. 11/28/2018

61. "We cant change the human condition, but we can change the conditions under which humans work"
James Reason