1. Patient Safety Champions Programme Day 1

2. The AQuA Team Amanda Bernie Hannah

3. Join the conversation.. #SaferNHS @AQUA_Inform

4. Programme Objectives Understand the trust context and principles of patient safety Develop a measureable safety initiative Explore the challenges that impact safety efforts Recognise & encompass human factors Increase likelihood of success & sustainability.

5. Programme Flow

7. Kirkpatrick Model

8. Getting to Know You

9. Please take a post-it note from your desk and write a random fact about yourself on it – it can be work or non-work related and the more random the better! You must be willing to share your fact during the course, and it must be something that can be shared in public but please keep it secret for now! Please write your name at the bottom, fold it up and give it to one of the facilitators 9

10. Along the way…

12. Skills Assessment Online Via: https://www.surveymonkey.net/r/?sm=CNDiUI4j3V%2bB93xgLmcvsmSYPQ14C%2f8mqldG9sOAQou4W%2f lxfv%2fjMUC2o1LIRIowwHgvi3Zs1Ko1tZH0UXrZobnHtoKvKohZbXtJ0TdN0MA%3d

13. Additional Input Initiative support / poster planning eleanor.barnard-croft@tgh.nhs.uk AQuA site (sign up needed)

15. Day 1 Objectives Have a better understanding about your organisations approach to safety Understand how we know (and measure) if change has improved safety Be able to understand changes that can be made to improve safety

16. Quality & Safety

17. Safe Improvement science and profound knowledge Patient Centered Quality Healthcare TimelyEfficientEquityEffective 6 Dimensions of Quality Healthcare Crossing the Quality Chasm: A New Health System for the 21st CenturyCrossing the Quality Chasm: A New Health System for the 21st Century, 2001 Institute of Medicine 17

18. NPSA 2004

19. Maintaining safety in our current climate ….

20. Safety & QI isn't a new thing, it’s the right thing Scuatari Barracks Hospital Turkey 1854

21. 21 Florence Nightingale (1859) Notes on Hospitals Reviewed best practice across Europe & UK Avoidable deaths reduced by 99% in a year Took positive local action (stopped immediate cause of harm) Patient safety leader

22. Francis. Feb 13 Berwick. Aug 13 Keogh. July 13 150 years on …..

23. Quality Improvement The Science

24. Improvement Science - What is it? Improvement science is an emerging field of study focused on the methods, theories and approaches that facilitate or hinder efforts to improve quality and the scientific study of these approaches. Source: The Health Foundation, Improvement Science Evidence Scan, Jan 2011 ‘the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better outcomes (health), better system performance (care) and better professional development (learning).’ Paul Batalden & Frank Davidoff 2007

25. The Quality Pioneers 25 W Edwards Deming 1900-93 American engineer, statistician, professor, author, lecturer, and management consultant Scientific pioneer of quality control. Walter Shewhart 1891-1967 American physicist, engineer and statistician Father of statistical quality control. Invented the Shewhart Cycle Joseph Juran 1904-2008 Romanian born American management consultant and engineer Advocate of quality & quality management

26. Safety & QI isn't a new thing, it’s the right thing Scuatari Barracks Hospital Turkey 1854

27. 27 Florence Nightingale (1859) Notes on Hospitals Reviewed best practice across Europe & UK 16000 or 18000 avoidable deaths reduced by 99% in a year Took positive local action (stopped immediate cause of harm) Patient safety leader

28. Francis. Feb 13 Berwick. Aug 13 Keogh. July 13 150 years on …..

30. 30 Two Types of Knowledge Subject Matter Knowledge Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge. Profound Knowledge: The interaction of the theories of systems, variation, knowledge, and psychology. Profound Knowledge

31. Deming’s System of Profound Knowledge 31 The aim chapter is to provide an outside view – a lens – that I call a system of profound Knowledge. It provides a map of theory by which to understand the organizations that we work in.” (Deming 1993 p. 92) Appreciation of a System Understanding Variation Theory of Knowledge Psychology Subject Matter Knowledge Knowledge for Improvement

32. You initiative: components of profound knowledge Take 5-10 mins to consider the system that you will seek to improve. Map & discuss the issues related to the project that arise from each component of the System of Profound Knowledge: –which systems will your project impact? –what variation do you know about or expect? –how will your project impact people (colleagues, team members, other depts.)? –what beliefs do you have about your project and how will you test them? 32

33. Paul Batalden Dartmouth Medical School, New Hampshire, USA. “Every system is perfectly designed to get the results it achieves” 33

36. Deming’s System of Profound Knowledge 36 Appreciation for a System Interdependence, dynamism World is not deterministic Optimization, interactions Containing systems, subsystems Understanding Variation Variation is to be expected Common or special causes Ranking, tampering System capability Theory of Knowledge Prediction Learning from theory, experience Operational definitions PDSA for learning and improvement Psychology of change Interaction between people Motivation Beliefs, assumptions Inferences From L. Provost

37. Unintended Consequences 

38. “Real improvement comes from changing systems, not changing within systems.” – Berwick 38

39. Reactive change Made to solve immediate problems or react to a special circumstance. Often result in putting the system back to where it was sometime before. Result is usually felt immediately or in the near future Proactive change Initiate changes before problems occur Causing something to happen rather than waiting for it to happen Result felt later on-not always obvious 39 Reactive vs Proactive

40. 40 Quality Old Way v New Way Quality Better Worse Old Way (Quality Assurance) New Way (Quality Improvement) Threshold No action taken here Action taken on all occurrences Action taken here

41. Initiative planning using a quality improvement model

42. Development & Success The Model for Improvement has been proven nationally and internationally over the past 20 years Work led by the Institute for Healthcare Improvement (IHI) and other organizations that focus on operational efficiency and improved clinical outcomes in health care.

43. Model for Improvement 43

44. Empathy the Human Connection to Patient Care VideoEmpathy the Human Connection to Patient Care Video The Wigan Empathy video 44

45. What does your initiative mean to patients, staff, carers, family, friends? 45

46. What is the evidence to support the need? Who has an interest in this area? Would they be on your expert panel? How is it aligned to your organisation’s quality and safety strategy? Who are your stakeholders? How will it impact patient care, staff satisfaction & involvement and the wider health economy? Initiative Rationale 46

47. Setting a safety aim What are you trying to accomplish? By how much? By when? For whom(or what system)? Remember to be SMART & Safe 47

48. When writing an aim statement consider …. Brief rationale What’s the problem? Why is it important? What are we going to do about it? What exactly are you trying to achieve? For whom are you going to improve it for? By how much will you improve it? By when are you aiming to achieve it? 48 Adapted from

49. Diagnosing your problem 49

50. Sometimes its obvious when things need to change… 50

51. But before we start………do you really understand the problem?? Solution vs Problem

52. © 2014 AQuA

53. How do you know what needs improving? Quantitative dataQualitative data

54. Why, why, why?! ‘Results indicate that when preschoolers ask "why" questions, they're not merely trying to prolong conversation, they're trying to get to the bottom of things.’ © 2014 AQuA http://www.sciencedaily.com/releases/2009 /11/091113083254.htm Frazier et al. Preschoolers' Search for Explanatory Information Within Adult-Child Conversation. Child Development, 2009; 80 (6): 1592 DOI

55. Consider using 5 whys This could take any number of “whys” to get to the root cause of the problem Do not stop until you reach what you believe is a “cause” and not a “symptom” If you reach a cause that cannot be controlled, such as weather, go back one level and see if eliminating that cause will help 55

58. Process mapping is…… …..a methodology to assist in the streamlining of processes in a system, and assist with the elimination of waste (such as time and resources) by focusing on the values of its practices to the people that use them.

59. Maps Proces s Map Value Stream Map

60. What is a process? Definition : a process is a series of connected steps or actions to achieve an outcome Scope: it has a first step and a last step Processes: cross organisational, departmental and professional boundaries - There are usually constraints and or bottlenecks - It can be mapped to different levels of detail

61. Current state

62. Top tips

63. Diagrams © 2014 AQuA Spaghetti Fishbone

64. Fishbone diagram A systematic and structured method for identifying potential root causes of failures –Classifies potential causes for a failure into separate categories –Very logical and analytical method of determining potential causes for failures

65. © AQuA Academy65

66. Driver Diagrams

67. 67

68. Driver Diagrams – why use them? Breaks down any broad aim, graphically, into increasing levels of detailed actions that must or could be done to achieve the stated aim Helps to focus on the cause and effect relationships that exist in complex situations. Well defined drivers that can form the focus of improvement efforts. 68

69. What are the component parts? Aim or goal of the improvement effort Primary drivers - system components that contribute directly to the chosen aim or goal. Processes, rules of conduct, structure Secondary drivers - elements of the primary drivers and which can be used to create change projects. Components and activities Relationship arrows - show the connection between the primary and secondary drivers. A single secondary driver may impact upon a number of primary drivers 69

70. 70

71. © 2010 AQuA 71 Aim A reduction in the numbers of recorded STFs by 20% in the Unit during 2014/15 from the 13/14 baseline. Care Planning/Medications Environment Workforce A. Raise awareness of history of falls B. Introduce a SU advanced statement re care. C. Medication review A. Post all records (agreed actions) of the community meetings in a central area. B. Post a weekly activity programme at a central point on the ward c. Declutter exercise.. A. Develop a formal process regarding the planning of social & therapeutic activities. B. Introduce a community meeting. C. Redesign zonal observations Example: Driver Diagram Primary drivers are the systems changes which will contribute to achieving the Aim outcome measure. Secondary drivers are interventions associated with primary drivers. They can be used to create projects or change packages that will affect the primary driver. A. Review and compare data – make data easily available to staff.. B. Identify specific times/places/ of falls. C. Provide poster for staff comments re new PDSAs. D. Review process for observation. E. Recruit permanent staff to vacant posts. Therapeutic Intervention s Primary Drivers Secondary Drivers

72. Developing Drivers Dedicate time for team and subject matter experts – ask them to come prepared! Revisit your aim statement. Brainstorm potential Primary Drivers & check –’If I made an improvement in this driver what would it achieve?’ –’If I could influence (or improve) against all of these drivers is there anything else that could go wrong and prevent me achieving my aim?’

73. © 2010 AQuA 73 Aim A reduction in the numbers of recorded STFs by 20% in the Unit during 2014/15 from the 13/14 baseline. Care Planning/Medications Environment Workforce A. Raise awareness of history of falls B. Introduce a SU advanced statement re care. C. Medication review A. Post all records (agreed actions) of the community meetings in a central area. B. Post a weekly activity programme at a central point on the ward c. Declutter exercise.. A. Develop a formal process regarding the planning of social & therapeutic activities. B. Introduce a community meeting. C. Redesign zonal observations Have a Go: Driver Diagram Primary drivers are the systems changes which will contribute to achieving the Aim outcome measure. Secondary drivers are interventions associated with primary drivers. They can be used to create projects or change packages that will affect the primary driver. A. Review and compare data – make data easily available to staff.. B. Identify specific times/places/ of falls. C. Provide poster for staff comments re new PDSAs. D. Review process for observation. E. Recruit permanent staff to vacant posts. Therapeutic Intervention s Primary Drivers Secondary Drivers

74. Lift Speech Develop elevator pitch to ‘sell this’ to the team you are meeting 30 second speech to explain project/ focus areas for QI to others. Snappy….so it’s remembered! Should reflect the Aim Used consistently 74

75. PDSA In Action!

76. PDSA Cycles

77. Pace & pressure Smaller Scale Tests: One patient, one staff, try it once to get started, talk it through before trying Test Multiple Drivers: Assign individual responsibility for testing changes Test Multiple Change Ideas: Work in parallel to accelerate learning Use Volunteers: Don’t waste time persuading! Instant feedback: PDSA means you know if it worked & you don’t need to wait 2 weeks for someone to tell you!

78. PDSA your project Use workbook 5 mins today Revisit day 2 and 3 Think small!

79. QI is a journey taken in baby steps not giant leaps

80. Presenting data, knowing you’re making a difference © 2014 AQuA

83. Cause & effect: driver diagrams Helps you to think about the aim that you want to achieve and more importantly what necessary changes you need to make Simple way of organising visually the actions that will help you achieve your aim

84. © 2014 AQuA

87. For day 3 (15 TH dec) initiative support Complete your reflective log and consider the impact of todays learning on your initiative ‘Firm up’ and bring your revised initiative aim statement Complete a draft driver diagram Draft a measurement plan (bring data) Consider a small PDSA test