1. Insert name of presentation on Master Slide Improving quality by changing the service

2. A model for improvement www.1000livesplus.wales.nhs.uk What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you seek ? Aims Measurement Ideas, hunches, other people etc. Three fundamental questions for improvement ActPlan StudyDo How to make change happen Langley et al (1996) – cited 1000 Lives plus (2012)

3. www.1000livesplus.wales.nhs.uk What are you trying to accomplish? Aims How will you know that a change is an improvement? Measurement What changes can you make that will result in the improvements you seek ? Ideas, hunches, etc. Three fundamental questions for improvement

4. The PDSA Cycle www.1000livesplus.wales.nhs.uk How to make change happen … ActPlan Study Do Walton (1989) Objective What do we want to do? Plan to carry out the cycle (who, what, where, when) Plan for data collection

5. www.1000livesplus.wales.nhs.uk In every work place (and home) there are 4 people named Everybody, Somebody, Anybody and Nobody. is When there is a job to be done Everybody is asked to do it. Everybody is sure Somebody will do it. Anybody could do it, but Nobody does it. Somebody will get angry about that because it is Everybody’s job to do it. However, Everybody thinks Anybody could do it and Nobody realises that Everybody won’t do it, unless Somebody does. It will end up with Everybody blaming Somebody because Nobody does what Anybody could do.

6. The PDSA Cycle www.1000livesplus.wales.nhs.uk How to make change happen … ActPlan Study Do Walton (1989) Objective What do we want to do? Plan to carry out the cycle (who, what, where, when) Plan for data collection Just do it! Carry out the plan Document problems and unexpected observations Analyse the data What did or didn’t work? Summarise what was learnt What changes are to be made? Next cycle?

7. Repeated PDSA Cycles www.1000livesplus.wales.nhs.uk Hunches Theories Ideas Changes that result in improvement DS AP DS AP DS AP DS AP

8. A model for improvement www.1000livesplus.wales.nhs.uk What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you seek ? Aims Measurement Ideas, hunches, other people etc. Three fundamental questions for improvement ActPlan StudyDo How to make change happen Langley et al (1996) – cited 1000 Lives plus (2012)

9. A real example of process mapping in practice … www.1000livesplus.wales.nhs.uk

10. Burns Unit Quality Improvement Team Team Members: – Consultant Surgeon, Ward Sister, Nursing Staff, Clinical Psychologist, Physiotherapist Aim: –“to improve the quality of care to adults with major burns so that they receive the care they need” www.1000livesplus.wales.nhs.uk

11. Top-down Process mapping www.1000livesplus.wales.nhs.uk Accepting referral Discharging from acute phase AssessingTreatingEvaluating

12. Top-down Process mapping www.1000livesplus.wales.nhs.uk Accepting referral Discharging from acute phase Assessing -Enquiring about the patient - Preparing for arrival - Advising on initial treatment - Taking Clinical baseline - Informing relatives and carers -Taking swabs and photos -Treating other medical conditions -Responding to Psych needs - Mobilising and moving - Managing pain - Planning for discharge - Evaluating wound - Evaluating Psych progress - Sharing info at case conf. - Feeding back to patient and carers - Evaluating infection status -Organising follow-up appointment - Writing & sending discharge letter - Providing appropriate patient info - Giving SOS contact Treating -Enquiring about the patient - Preparing for arrival - Advising on initial treatment Evaluating

13. Some areas identified for improvement Providing appropriate information to patients and carers when they need it Receiving and accepting referrals Criteria for agreeing surgery Identifying patients who need psychological support www.1000livesplus.wales.nhs.uk

14. Accepting referral Discharging from acute phase AssessingTreatingEvaluating -Enquiring about the patient - Preparing for arrival - Advising on initial treatment - Taking Clinical baseline - Informing relatives and carers -Taking swabs and photos -Treating other medical conditions -Responding to Psych needs - Mobilising and moving - Managing pain - Planning for discharge - Evaluating wound - Evaluating Psych progress - Sharing info at case conf. - Feeding back to patient and carers - Evaluating infection status -Organising follow-up appointment - Writing & sending discharge letter - Providing appropriate patient info - Giving SOS contact Top-down Process mapping www.1000livesplus.wales.nhs.uk

16. Swiss Cheese management model www.1000livesplus.wales.nhs.uk

17. A key area for improvement www.1000livesplus.wales.nhs.uk To improve the identification of patients who need psychological support

18. www.1000livesplus.wales.nhs.uk What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you seek? What are we trying to accomplish? to improve detection of psychological distress

19. www.1000livesplus.wales.nhs.uk What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you seek? What are we trying to accomplish? to improve detection of psychological distress How will we know a change is an improvement? - screening results will be available in notes - appropriate referrals to psychology

20. www.1000livesplus.wales.nhs.uk What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? What are we trying to accomplish? to improve detection of psychological distress How will we know a change is an improvement? - screening results will be available in notes - appropriate referrals to psychology What changes can we make that will lead to improvement? - introduce a screening tool for selected patients - try a pilot with 5 patients

21. www.1000livesplus.wales.nhs.uk ActPlan StudyDo What are you trying to accomplish? How will you know that a change is an improvement? What changes can you make that will result in the improvements you see? Study: - inclusion/exclusion criteria were unclear and there were errors in scoring Do: - tested screening tool Plan: - refine criteria - workshops for nurses Study: - screening was more accurate but implementation was patchy Plan: - build reminders into ward routines D S AP PDSA 1 Study: - showed significant improvements D S AP PDSA 2 D S AP PDSA 3

22. www.1000livesplus.wales.nhs.uk Results after third PDSA 91% of patients were being checked Approximately 30% were found to need psychological support for anxiety, depression or PTSD Referrals to Clinical Psychology increased by 600% Burns Unit Quality Improvement Team

23. Listen to the Story www.1000livesplus.wales.nhs.uk –How does listening to the story make you feel from a personal point of view? –If you had this situation presented to you, what would you do about it?

24. An Overview of Improvement www.1000livesplus.wales.nhs.uk –Success is defined as improving how we safely and humanely meet the needs of our patients –Focus on processes, not blaming others –Success depends on gathering and using data and information to identify changes and to learn from testing them out … … …

25. … … … Overview (cont.) www.1000livesplus.wales.nhs.uk –Using rapid small changes engages staff and creates continuous improvement –Success requires collaboration and innovation from team members working together –Combining professional knowledge with improvement knowledge is very powerful for providing safer and better care

26. www.1000livesplus.wales.nhs.uk Workshop activity Report back on the activity (waiting room or following signs) and discuss how patient focused they are. Go back to the process map you have undertaken and consider the PDSA cycle … Plan a change (the P of PDSA) Consider all the changes you can.

27. Bibliography Batalden PB & Stoltz PK (1993) A Framework for the Continual Improvement of Healthcare: Building and Applying Professional and Improvement Knowledge to Test Changes in Daily Work. Journal on Quality Improvement, October. 19 (10) 424-452 Berwick DM (1996) A primer on leading the improvement of systems. BMJ 312 619-622 Cox S, Wilcock P & Young J (1999) Improving the Repeat Prescribing Process in a Busy General Practice - A study using continuous quality improvement methodology, Quality in Health Care, 8 119-125 Maxwell RJ (1984) Quality assessment in health. BMJ; 288: 1470-2 Nelson G, Batalden P, Plume S, Mohr J (1996) Improving Health Care Part 2 - A Clinical Improvement Worksheet and Users’ Manual. The Joint Commission Journal on Quality Improvement. 22 (8) 531- 548 1000 Lives Plus (2012) The Quality Improvement Guide for Educators and Students. Available on line at; www.1000livesplus.wales.nhs.ukwww.1000livesplus.wales.nhs.uk Øvretveit J. (1992) Health Services Quality: An introduction to quality methods for health services. Blackwell Scientific. London Scholtes PR, Joiner BL, Streibel JL (2003) The Team Handbook – 3rd Edition. Pub: Oriel Inc. www.1000livesplus.wales.nhs.uk

28. Useful Links www.1000livesplus.wales.nhs.uk www.1000livesplus.wales.nhs.uk 1000 Lives Plus, NHS Wales www.ihi.org www.ihi.org Institute for Health Care Improvement (USA) www.teamhandbook.com www.teamhandbook.com Website for the Scholtes et al (2003) referenced above www.patientvoices.org.uk www.patientvoices.org.uk Recordings of patient experiences. www.1000livesplus.wales.nhs.uk