1. Quality Improvement and Transformation
Annette Bartley RGN BA (Hon) MSc MPH
Director of the Safer Patient Network
Health Foundation/ IHI Fellow
Co-facilitator of CHAIN QI sub-group
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© Annette Bartley Consulting Limited

2. Why do we need to improve?
Despite a decade of government initiatives to make healthcare safer one in ten patients continue to be harmed as a result of hospital treatment, .
Avoidable harm!
As this table show healthcare is more hazardous than sports such as mountain climbing and bungee jumping.
Patient Safety needs to be seen as the number one priority within healthcare organisations. The “first do no harm” principle
South Central is to be commended for recognising the importance of patient safety and for making it the priority across the region
It is important to recognise however that safety is a key component in the much broader quality improvement agenda
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©Annette Bartley Consulting Limited

3. The Centers for Medicare & Medicaid Services
QI is a "set of related activities designed to achieve measurable improvement in processes and outcomes of care. Improvements are achieved through interventions that target health care providers, practitioners, plans, and/or beneficiaries."6,7
The Centers for Medicare & Medicaid Services
Quality Improvement aims at “raising the bar” taking performance to a new improved level
Patient Safety aims at raising existing standards of care improving safety and process that already exist
The focus need be on both ends
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4. Institute of Medicine Aims
Safe (no needless deaths)
Timely (no unwanted waiting)
Efficient (no waste)
Effective (No needless pain or suffering)
Patient and family centred (no helplessness)
Equitable (for all)
IOM= Crossing the Quality chasm 2001 (IHI)
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5. First do no harm… Fundamentals of patient safety
Prevention
Detection
Mitigation
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6. The Reality in Practice
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7. System-Level Redesign
Every system is perfectly designed to achieve exactly the results it gets.
New levels of performance can only be achieved through dramatic system-level redesign.
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8. “Quality improvement begins with love and vision. Love of your patients. Love of your work. If you begin with technique, improvement won’t be achieved.”
Donabedian was a pioneer in the field of health-care quality, and he developed a basic framework in which to think about quality-improvement efforts. Donabedian defined the health-care triad of structure, process and outcome
A. Donabedian, M.D
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9. Bringing the Work of Many Initiatives into a Coherent Whole
National Patient
Safety Agency
(NPSA)
Safety Alerts
Matching Michigan
Health Foundation
Safer Communities
CNO High Impact Changes
The Patient Safety First
Campaign
NHS III
LIPs
Productive
Series
QIPP
Safer Patients
Network (SPN)
The Health Foundation
(with IHI)
WHO World Alliance
for Patient Safety
Over the last few years as you will know Quality and Safety has been rising to the top of the political agenda. Whilst this is a indeed a positive, it has resulted in a the development of a plethora of QI& PS projects/ initiatives with many overlapping, often uncoordinated and few resulting in lasting change.
The need to bring the work of these many initiatives together into a coherent whole is evident.
NICE
Quality Standards
Department of Health
(DoH)
High Quality Care for All
IP&C
CMO England
VTE
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10. From what… to how A little less conversation a little more action
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11. Deming’s Thoughts on Transformation
Metanoia:
Reorientation of one’s way of life
(The New Economics. Deming, p. 95, 1993)
Begins with individual
More than a change
Develop new habits of mind
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12. Where to begin
Will
Ideas
Execution
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13. Executive Perceptions vs. Frontline Perceptions:
Executives overestimate:
Teamwork Climate 4X
Safety Climate 2.5X
Executive Confidence vs. Executive Accuracy:
-Often wrong but rarely in doubt…
-Currently no incoming data-streams
-Halo Effects
-Frontline data fills the gap 13

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15. Health Care Processes Desired - variation
based on clinical criteria, no individual autonomy to change the process,
process owned from start to finish,
can learn from defects before harm occurs, constantly improved by collective wisdom - variation
Current -
Variable, lots of autonomy
not owned,
poor if any
feedback for improvement, constantly altered by individual changes, performance stable at low levels
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Terry Borman, MD Mayo Health System 15

16. Reliability Post office Ritz Carlton Mc Donald’s Virgin Flights
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17. New Methods and Tools
Quality Improvement methodology consists of many of tools and techniques.
Shown here are the one’s we feel are necessary to all QI ventures
Asking the three simples questions on The MFI
Starting with small tests of change with sequential building
Then moves from the testing to implementing, spreading and sustaining the improvement
Monitoring of data over time
Using data to learn and to improve
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18. The Model for Improvement...
Aims
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 the improvements we seek ?
The three fundamental questions for improvement
Measurement
Ideas, evidence, hunches, other people etc.
Act
Plan
Study Do
The fourth question: how to make changes
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Langley, Nolan et al 1996

19. Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement? A P
What change can we make that S D
will result in improvement?
DATA D S
Implementation of Change P A A S P
Wide-Scale Tests of Change D
Hunches Theories Ideas A P S D
Follow-up Tests
Very Small Scale Test
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20. Small Scale Tests of Change on:
One clinic
One patient
One doctor
One nurse
One day / shift
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21. Where do I begin? Hunches & Theories Gap in knowledge
Set about testing your theory
Cause & Effect
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22. Steps to reliable care Do the acid test? Segment your population
Design an articulated process goal,
Agree a clear outcome goal connected to the process with some supporting evidence.
Use the prevent, detect, mitigate theoretical design to understand failures and to learn how to redesign
Design your first test of change
Determine the tempo of change
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23. Improvement requires a clear aim
Measurement & Action
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24. Process Eyes
Make the process for preventing Pressure Ulcers (&Falls) visible to ALL
Measure it -so we can ‘see’ if it is adhered to and effective
Make it easy for others to do the right thing (simple checklists, reminders)
The right process with high % compliance WILL influence outcomes

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27. Days without a hospital acquired pressure ulcer (ABM LHB Wales)
Clear Aim
Engaged Team
Simple measures-just enough data
Tests of change
Results
638
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28. Patients as partners
“ If quality is to be at the heart of everything we do, it must be understood from the perspective of patients.”
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29. Nothing about me without me
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30. The Value of Networks
“Good Networks are horizontal partnerships which value professional expertise and mutual learning. In doing so, they overcome hierarchy and create connections between different levels of the system. They are support structures for improving the quality of care and patient safety ”
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31. How can CHAIN assist the Allied Health Professions?
Motivate and inspire
Making Connections between individual improvers
Empowering professionals to use evidence
Sharing knowledge and experience
Tools and Techniques for Improving practice
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32. Research / online communities
Lurking
Linking
Learning
Leading
When developing a community that will not be meeting on a regular basis the dynamics are very different to one that meets regularly. Seeley in his research on development of on-line communities describes four stages of learning which I believe can be applied to developing communities of practice:
The 4 L’s
Lurking – Folks attend calls/meeting but don’t actively engage – they ‘lurk’ around the edges of the community
Linking- These folks then start to make connections and links between the work they are doing and the work of the community and to forge links with others in the community
Learning- Once immersed into the community they truly begin to learn
Leading- Strong connections are made , the learning is in progress and the application of learning and leading others in this work begins
A shift from passive to active participation
John Seeley-Brown 4 L’s
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33. Distributed leadership Marshall Ganz
“We got used to the politics of disappointment -- figuring out how soon we were going to be let down. ... There’s a different dynamic in the ... politics of hope. It’s much more challenging. It means you’ve got to get up and do something. There’s opportunity. If you don’t take advantage of that opportunity, you really have to bear responsibility for not doing so. That’s how I see the time we’re in. ”
Marshall Ganz

34. The Politics of hope Get organised! Find your carpenters!
Provide them with the tools!
Stand back as they get going!
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35. Michelangelo’s Thoughts on Transformation
“In every block of marble I see a statue as plain as though it stood before me, shaped and perfect in attitude and action. I have only to hew away the rough walls that imprison the lovely apparition to reveal it to the other eyes as mine see it.”
“I saw the angel in the marble and carved until I set him (her) free.” .... Michelangelo
“In every block of marble I see a statue as plain as though it stood before me, shaped and perfect in attitude and action. I have only to hew away the rough walls that imprison the lovely apparition to reveal it to the other eyes as mine see it.” Michelangelo
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36. Questions?
Hey… what’s a mountain goat doing way up here in a cloud bank?

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38. Managing improvement in the context of multidisciplinary teams
What does this mean to you?
Does anyone have experience/examples of working within an effective team?
What are the key characteristics of an effective team?
What about working in an ineffective team?
What might that look like?
What do teams need to enable them to improve the quality of care?
The sum of the whole is greater than the parts
Shared
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