1. SPICE and Service Improvement Methodology
Improving Quality in Practice. Approaching Improvement in a Complex System
SPICE and Service Improvement Methodology
Jonathon Gray
Director Healthcare Improvement
Wales Centre for Health

2. PARIS
IN THE
THE SPRING

4. PARIS
IN THE
THE SPRING

6. How many legs does this elephant have?

7. The First Law Of Healthcare Improvement
“Every system is perfectly designed to achieve exactly the results it gets”
Therefore, Although Not All Change Is Improvement, All Improvement Is Change
What’s it all about?
Delivering right care, at the right time, in the right place by the right person etc
Source: Don Berwick, IHI (Boston)

8. Welsh Policy Context Where are we going? What do we need?
Wales: A Better Country
Where are we going?
Designed for Life
What do we need?
Healthcare Standards for Wales
What do we do?
The Healthcare Quality Improvement Plan: Designed to Deliver
How will we get there?

9. Aims for Improvement
“By 2015, Wales will have minimized avoidable deaths, pain, delays, helplessness, and waste.”
Designed for Life
Safety
Effectiveness
Patient Experience
Timeliness
Efficiency

10. “The needs of the patient come first…..”
No needless deaths
No needless pain or suffering
No unwanted waiting
No helplessness
No waste
……For anyone

11. What do we need to measure and why?
IHI Model for Improvement

12. CAUTION!
Gathering data can bring new and surprising knowledge to those who dare to seek it!

13. How Hazardous Is Health Care?

14. Hospital Death Rate (Standardized for Age, Sex, Race, Payer, Admission Source & Type) vs Charge per Admission (Standardized for Age and Diagnosis) -- AHRQ 1997 Data

15. Organisation with a Memory
15,000 to 70,000 adverse events each year in the Wales NHS hospital sector ( % of admissions)
£100 million direct cost in additional hospital days alone
Clinical negligence cost - £85m ( )
Half might be avoidable.
Source: Organisation with a memory - CMO England)

16. Essential Elements for Large-Scale Change
Will
Ideas
Execution

17. We will explore new ways of working, recognising that there may now
be better and different methods

19. The Knowledge Base for Continual Improvement
Subject and
Discipline
Knowledge
Knowledge for
Improvement
Systems
Variation
Psychology
PDSA +
Key Themes in SPICE methodology: Evidenced based
Aimed at collecting fact not anecdote
Builds on what the research and evidence so far tells us IC should look like
Tests it, critically evaluates, highlights areas for improvement
Continual Improvement

20. The Project Method: The Model for Improvement (Nolan, et al.)
Act
Plan
Study Do
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 an improvement?
Key Themes in SPICE Methodology: Continuous Improvement
Using the Tool to identify small scale change projects and review their impact
CQI for the Tool itself; review and adaptation

21. 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 31

22. Leadership Set-up Better Ideas Social System Measurement and Feedback
-Target population Adopter audiences
-Successful sites Key partners
-Initial spread strategy
Social System
-Key messengers
-Communities Technical support
-Transition issues
Communication Strategies (awareness & technical)
Knowledge Management
Measurement and Feedback
Leadership
-Topic is a key strategic initiative
-Goals and incentives aligned
-Executive sponsor assigned
-Day-to-day managers identified
Better Ideas
-Develop the case
-Describe the ideas
Key Themes in SPICE methodology: Outcome focused
Clinical and social outcomes
Looks at whole person
Multi disciplinary approach
Checks what we’re doing achieves individual’s goals i.e. that we do good not harm
?? can link this to increased compliance & patient safety
Key themes in SPICE methodology: Practitioner Engagement
Practitioners involved in the development and testing of the tool
Ensures it’s relevant to their ethos and motivation
Success will be dependent on their continued feedback and suggestions for improvement
Key Themes in SPICE methodology: Sustainability & Spread
Supporting social movement by
- creating a network/Community of Practice
shared learning
joint problem solving
Spreading good practice
Keeping it live

23. Acknowledgements: Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation

24. Components of an Improvement System
STRATEGY
--Leadership
--System Aims
--Finance
--Training
--Environment
TECHNIQUE
--Statistics and Measurement
--Systems Knowledge
--Group Process
--PDSA
--Tools
CULTURE
--Teamwork
--Cooperation
--Operating Values
--Beliefs and Myths
MANAGING IMPROVEMENT

25. Justin

26. Justin Micalizzi (by Dale Ann Micalizzi)
“On January 15th, 2001, Justin, a healthy 11-year old boy, was taken into surgery to incise and drain a swollen ankle. He was dead by 7:55 a.m. the next morning, leaving behind two grieving and bewildered parents who desperately wanted to know why their son had died. But medical care was to fail them twice- first their son died and then no one would explain to them why.”

27. Justin Micalizzi (by Dale Ann Micalizzi)
I know the chaos, the nursing shortages, overtime, the financial obligations, the insurance company guidelines and the arrogance that interferes with the quality of care. I have worked in healthcare and education for over 20 years. I also know, when it came time for my son’s surgery, you remove the chaos. You develop a team effort to review all information and establish a plan. You openly communicate between specialists, remove arrogance and intimidation and have a common goal to heal. It is your obligation to complete checklists, check and double check medications and dosages, assign a nursing team and treat every case as a possible emergency with the patient as your ONLY focus. Look at the child; listen to the parents and use common sense and professional judgment when making all decisions. Slow down! You are holding my child’s life in your hands. Justin WAS important and should have been important to his healthcare providers also. I trusted you.

28. Justin Micalizzi (by Dale Ann Micalizzi)
The hospital failed us, the nurses who were his advocates failed us, and the technicians who didn’t draw pre-op labs failed us. And, most importantly, the surgeon who gave the case to the resident and was NOT even in the OR at the time of surgery failed us. The health department failed us by accepting the medical personnel’s information as truthful. The hospital CEO failed us by not providing us with any information or support. Error upon accepted error killed my son and my faith in a medical system that was meant to comfort and heal. We will not let this happen to another family. The pain is unbearable.

29. Justin Micalizzi (by Dale Ann Micalizzi)
“….. when it came time for my son’s surgery, you remove the chaos……”

30. The Simple, Wrong Answer
Blame Somebody

31. The First Law of Improvement
“Every System Is Perfectly Designed to Achieve Exactly the Results It Gets”
(Therefore, Although Not All Change Is Improvement, All Improvement Is Change)