1. Quality Improvement Processes, reliability and capacity Dr. Simon Watson NHS Institute for Innovation & Improvement

2. Mechanics of quality improvement Define your quality metric Measure it Change your system Check for improvement – re-measure

3. Why do some quality improvement initiatives fail?

4. Because change isn’t easy

5. Major obstacles to change Habit – what a person usually does Culture – what an organisation usually does Successful improvement initiatives change habits and cultures A strategy to implement these changes is essential

6. Culture Vs Strategy Not a fair fight

7. Sometimes Always “Reliability means keeping a promise” Reliability What is reliability?

8. Reliability Reliability = error free operations total number of operations 90% 99% 99.9% 99.99% 99.999% 99.9999%

9. Reliability in healthcare 40% http://www.aware.md/images/handwashing.jpg

10. Example – the Ventilator Bundle Elevation of the head of the bed Daily “sedation vacations" and assessment of readiness to extubate Peptic ulcer disease prophylaxis Deep venous thrombosis prophylaxis

11. Example of 3 Step Design in Implementing the Ventilator Bundle Integrate daily goals with MDR to identify defects as a Education Baseline Feedback on compliance RT built into 1 hour scheduled vent checks as a) Example of using 10 -1 and 10 -2 change concepts to initially reach a reliability of 10 -1 then additionally using a robust 10 -2 change concept (redundancy) to reach 10 -2 reliability in the 4 elements of the ventilator bundle (Baptist Memorial, Memphis)

12. 12 months to achieve 100% compliance with ventilator bundle

13. Implementing change Measure whether your change is being implemented…… ……….before you look for improvement Assume full implementation will take time Have a strategy to achieve full implementation Failed change and failed implementation of change are different things

14. Designing reliable processes

15. Human vigilance, memory and professionalism These alone will NOT achieve reliability

16. Designing for reliability Use protocols whenever possible Simulate protocols to before use ‘in anger’ Check lists to support protocol Automatic alerts – computer screen, emails etc. Feedback on compliance

17. Key features of protocols Evidence-based Lead to good decisions Easily comprehensible Readily available Co-designed with intended users Process for continuous improvement

18. The limits of process-controlled management

19. Common cause variation

20. Special cause variation

21. Types of variation Special cause variation = Unusual variation Managing special cause variation:- Suspend protocol Get expert input

22. Capacity The maximum work that can be done in a given time

23. Management Charge Nurse Specialist Nurse Junior C/N Staff Nurse Consultant Cons. Deputy

24. Traditional process

25. Do all steps add value? Treatment Blood test performed Result published Nurse gets result Nurse tells doctor Doctor adjusts prescription Nurse effects Change to treatment

26. Treatment Blood test performed Result published A ‘lean’ process Nurse gets result Nurse effects Change to treatment “Expert” Special cause variation

27. Management Charge Nurse Specialist Nurse Junior C/N Staff Nurse Consultant Cons. Deputy

28. Summary Great improvement plans aren’t enough Plans are completely dependant on the processes that deliver them Recognise that change is challenging Finally……

29. THINK PROCESS RELIABILITY CABABILITY

30. Simon Watson simon.watson@institute.nhs.uk simon.watson@nhs.net 0796 991 6068

31. END

33. Test performed Result published Nurse gets result Nurse tells Dr result Dr. changes script Change effected

34. Treatment Test efficacy (blood test) Optimise treatment Basic process diagram

35. Improvement plans are likely to fail if they aren’t implemented reliably