Presentation on theme: "Getting to Zero-Safer Care Improvement Programme"— Presentation transcript:
1 Getting to Zero-Safer Care Improvement Programme Annette Bartley RGN BA MSc MPHHealth Foundation/IHI Quality Improvement Fellow
2 Learning Session 1 Overview Welcome & IntroductionsBackground and ContextProgramme aims & objectivesLinks to other workOverview of Quality ImprovementTools & techniquesMeasurement for improvementThe role of local coachesRefreshment breakTeam Presentations / Storyboard roundingLunchThe Snorkel – Generating Ideas from frontline staffRefreshment breakAction planning and report outSummary next steps and close
3 Understanding the context of frontline care What’s good about it?What’s not so good?What could be improved?
4 It’s a Fact that … “Without good and careful nursing many must suffer greatly, and probably perish, that might have been restored to health and comfort, and become useful to themselves, their families, and the public, for many years after.” Benjamin Franklin (1751)As early as 1751 Benjamin Franklin recognized the power and influence of nursing. He described the benefits of good and careful nursing, whilst pointing out the potential consequence of its absence. This is power each and every one of you has, you can positively impact on patients in so many ways, and our roles as nurses provide us with an extraordinary opportunity to influence. “With great power comes great responsibility “ we need to recognise and value the privilege
6 How do we make sense of all the expectations & bring the work into a coherent whole Health FoundationSafer CommunitiesNational PatientSafety Agency(NPSA)Safety AlertsMatching MichiganCNO High Impact ChangesQUIPP & Safety ExpressNHS IIILIPsProductiveSeriesSafer PatientsNetwork (SPN)The Health Foundation(with IHI)WHO World Alliancefor Patient SafetyOver 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.NICEQuality StandardsDepartment of Health(DoH)High Quality Care for AllIP&CCQUIN targets
8 Anita Tucker and Steve Spear describe how nurses spend the majority of their time being interrupted and hassledWe have becomes master of the workaround and as a result patients are suffering. The literature tells us that nurses spend on average about 25% of their time in care that provides value for patients ( ranging from between 18%-40%). Initiatives like the Productive ward have helped nurses release time to care but my challenge to you all is “so what” more time is great but use it wisely to achieve demonstrable results in patients outcomes and a better experience of care8
9 The politics of hope“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
10 Transforming Patient Experience Metanoia:Reorientation of one’s way of life(The New Economics. Deming, p. 95, 1993)Begins with individualMore than a changeDevelop new habits of mindWhat is transformation and what does it mean for ach of you and for the wider community?
12 Programme Aims Alignment with Safety Express To reduce the incidence of Avoidable Hospital /Community Acquired Pressure UlcerReduce of Falls (falls with harm)Reduce Catheter Associated Urinary Tract Infections (CAUTI)Prevention of Venous Thromboembolism( VTE)
20 Pressure Ulcers The “Case for Change” National Focus on Patient SafetyI in 10 patients harmed by what we doPoor Public Perception of CareImpact of financial cutbacksPressure Ulcer Incidence 1 in 5As high as 1 in 3
21 Prevention of Falls (Harm from falls) Falls prevention is a complex issue crossing the boundaries of healthcare, social care, public heath and accident prevention.Across England and Wales, approximately 152,000 falls are reported in acute hospitals every year, with over 26,000 reported from mental health units and 28,000 from community hospitals.A significant number of falls result in death or severe or moderate injury, at an estimated cost of £15 million per annum for immediate healthcare treatment alone (NPSA, 2007).
22 FactsPressure sores are an increasing problem that affect thousands of people unnecessarily every year..They are painful, debilitating and can be life threateningThe cost of treating a pressure ulcer varies from £1,064 -£10,551 with the estimated total cost in the UK of between £1.4–£2.1 billion annually- 4% of total NHS expenditure (Bennett et al 2004)Pressure ulcers represent a very significant cost burden in the UK. Without concerted effort this cost is likely to increase in the future as the population ages. Annual spend on dressing materials by the NHS of £89 million (DoH 2005).
23 What matters most to inpatients. Consistency and coordination of careTreatment with respect and dignityInvolvementDoctorsNursesCleanlinessPain control
24 Methods and ToolsQuality Improvement methodology consists of many of tools and techniques.Shown here are the one’s we feel are necessary to all QI venturesAsking the three simples questions on The MFIStarting with small tests of change with sequential buildingThen moves from the testing to implementing, spreading and sustaining the improvementMonitoring of data over timeUsing data to learn and to improve
25 4/14/2017Change vs. ImprovementOf all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress.W. Edwards DemingWe must become masters of improvementWe must learn how to improve rapidlyWe must learn to discern the difference between improvement and illusions of progressMCPP Healthcare Consulting
26 The Lens of Profound knowledge DemingAppreciationof a systemTheory ofKnowledgePsychologyCQIAims or valuesUnderstandingVariation
27 Quality Improvement Methods /Tools The Model for ImprovementThe Science of ReliabilityDriver DiagramChange PackageLean/5SSafety Cross/ Safety ThermometerSSKIN Bundle/ Intentional Rounding
28 The Model for Improvement will underpin the programme, enabling teams to connecting an aim to action and measurement which will enable you to demonstrate their progress.
29 Improvement requires a clear aim Measurement & Action
30 AIM How good do you want to be and by when? Make your aims SMART Aims infuse meaning and hope in our lives, they create a target to achieve and inspire and motivate us to achieve it.How good do you want to be and by when?Make your aims SMARTSpecificMeasurableAchievableRealisticTimelyGoals and aims help in taking some of the crucial decisions of our lives. You can actually decide what do you want and chalk out a plan to achieve it. Lack of an organized planning or aim, one may wander aimlessly and time might take decisions for us. Aims infuse meaning and hopes in our lives, it creates a target to achieve and inspire and motivates us to get it.
31 Appropriate preventative Developing a systems-based approach to the prevention of hospital acquired pressure ulcersRisk IdentificationWhat will success look like?Risk AssessmentCommunication ofRisk statusAppropriate preventativestrategy implementedEvaluation of outcome
32 The “Case for Change” National Focus on Patient Safety I in 10 patients harmed by what we doPublic Perception of CareImpact of financial cutbacksStrong link between Patient Satisfaction & Employee Satisfaction
33 Purpose of Using Data & Measuring The purpose of measuring is to answer critical questions and to guide intelligent action.Cliff Norman- Associates in Process Improvement
35 “In God we trust. All others bring data.” W. E. Deming
36 S+P=0 S=Structure The environment in which health care is provided P=ProcessThe method by which health care is providedO=OutcomeThe consequence of the health care providedAvedis Donabedian Physician
38 Three Types of Measures Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result?Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome)2
39 Measurement Guidelines A few key measures that clarify a team’s aim and make it tangible should be reported, and studied by the team, each monthBe careful about over-doing process measures for monthly reportsMake use of available data bases to develop the measuresIntegrate data collection for measures into the daily routinePlot data on the key measures each month during the life of the project
40 Measurement Guidelines The question - How will we know that a change is an improvement? - usually requires more than one measureA balanced set of five to eight measures will ensure that the system is improvedBalancing measures are needed to assess whether the system as a whole is being improved
41 Measurement- It is YOUR data!! (data MUST be locally owned) Outcome measuresIncidence ( count on safety cross)Days between eventsProcess measuresPercent Compliance with risk assessmentPercent Compliance with process ( bundle)Percent compliance with Intentional Rounding toolBalancing measuresPatient ExperienceStaff satisfactionLength of StayComplaintsStaff turnover /Sickness ratesBudget implication
42 Visual Measurement Days since last... ___ days 1 2 3 4 5 6 (3) 7 8 (1) 91011121314151617181920 (1)21222324 (1)25 (1)26Days since last...2728 (1)___ days293031
44 It’s time…A little less conversation a little more action
45 Getting it right Co-ordinating Care Multitude of Activities Confronting HospitalsCreates Initiative Overload. Managing a ward frontline unit in primary/secondary care is like conducting an orchestra.Timing , co-ordination, everyone coming in at the right time, reading the signals, supporting each other, doing your bit to the best of your ability whilst being sensitive and aware of the whole. You can create a beautiful symphony or a generally horrific noise.
46 Health Care Processes Current - Variable, lots of autonomy not owned, poor if anyfeedback for improvement, constantly altered by individual changes, performance stable at low levelsDesired - variationbased 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 - variationTerry Borman, MD Mayo Health System46
47 Intentional Rounding The Evidence The Studer GroupAlliance for Health Care Research38% Reduction in Call Lights12 point mean increase in Pt Satisfaction50% reduction in patient falls14% reduction in pressure ulcersFlaws in the study but…
48 On Finding What Works…“We need to standardize, simplify, and steal shamelessly from everyone who can contribute, because we’ve reached a point where no excuses are allowable.” Roger Resar, MD Senior Fellow, IHI
49 Intentional Rounding – What is it? Structured process where frontline staff regularly round on patients and reliably perform scheduled/required tasksRounding with purpose- linked to an aim8 key behaviorsOpening key words – managing upPerform scheduled tasksAddress the 3 p’s of pain, potty? position (SKIN Bundle)(toileting), andAssess comfort needsEnvironmental assessmentClosing key wordsExplain when you or others will returnDocument the round on the log
50 OMHS Intentional Rounding - wins 59% reduction in Pressure ulcers54% reduction in call lights(2878 fewer calls after rounding)Patient feedback – ‘I know someone will be back to check on me, when they come…’Improved employee satisfaction – 5.67 on a 7 point scale compared to national norm of 4.66 (Baird and Borling)Reduction in cost$3.02/pt 6 month avg. prior$2.39/pt 8 months avg. following
55 Intentional Rounding -Benefits Provide staff with better control of their timeImproved outcomes / promote safetyResultsIncrease Patient SatisfactionDecreases anxietyIncrease trust and give sense of comfortIncrease Employee Satisfaction
56 Additional Benefits Centred on patients/Catches all Provides a quality assurance framework for nursing careHelps to evidences what nurses doHelps demonstrates the impact on patient outcomesPotential to impact on the bottom line
57 It is the nature of systems that smaller systems are embedded in bigger systems 5757
58 ‘PDSA’s' ‘test’ a proposed change What they are not…A radical change to a system /processFull blown trust-wide implementationMini projects (monumental proportion)Top down directives‘PDSA’s' ‘test’ a proposed change
59 Paper Plane ExerciseAim – To design a paper plan that will fly the longest distanceAssign a design teamAssign someone to assemble the planeAssign a measurement person to measure the distance flown (in feet)Run your tests a few times?What are you learning?How are you factoring your leanring into the next test?
60 Patient &family centred care People are treated with respect and dignity.Health care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful.Individuals and families build on their strengths through participation in experiences that enhance control and independence.Collaboration among patients, families, andproviders occurs in policy and program development and professional education, as well as in the delivery of care.Source: Institute for Family Centred Care, Bethesda USA
61 Local Coaches/Facilitators Group of volunteersWilling to play a key role locally as coaches /facilitatorsSupport participants and help to accelerate momentum and the progressThey will be the links between you and the programme team
62 Storyboard rounding Split up into your teams Identify a space to display your storyboardSelect at least one member to present the findingsEveryone else will rotate around the teamsApproximately 7-8 mins to describe your team/aspirations/learning from pre-workBell will sound and teams will rotate to the next space
63 Harvest Identify three things you learnt during the rounding Could be meeting new peopleHarvesting Ideas from another teamResults/learning from their pre-work
69 Outline of “Snorkel” Review of Project Vision and Charter What do we know about ….Propose a Design ChallengeStorytellingHow might we….?BrainstormingSelect top ideas (multi-vote)Prioritize ideas for developmentPlan prototypesEnactmentsDesign first series of tests
70 StorytellingIn lieu of doing actual observations, use storytelling to “observe” actual experiencesRecall an actual story or experience which relates to the specific design challenge (personal, friend or family member or work-related experience)Who was involved?What happened?How did individuals feel and react?Give an exampleTell stories in small groups (nor more than 2 minutes each)
71 How might we….? (used to create ideas for the brainstorming) …. Prevent harm …Engage Patients and families in preventing harm …Optimise nutrition Ideas should be actionable Write each idea on post-it notes or flip c
72 Rules for Brainstorming (20 mins) Chose one or two “how might we scenarios….encourage wild ideasgo for quantity – want more than 500 ideasdefer judgmentbe visual – draw picturesone conversation at a timebuild on ideas of othersstayed focused on topic (“how might we…” scenarios)Write each idea on post-it notes
73 Multi-voting to Select Top Ideas Cluster together similar ideas from brainstorming exerciseUse dots to vote:What are your personal favorites?What idea would you most like to try on your unit?What idea do you think will have the biggestimpact toward achieving the “how might we…”Participants can distribute their dots however they want –- all on one idea, each dot on a separate idea, or anything in betweenReport out on favorite ideas (where there are most dots)
74 Matrix of Change Ideas Easy to Implement Low Cost High Cost Place concepts in matrix. Strive for easy, low-cost solutions. Translate high-cost solutions into low-cost alternatives.Low CostHigh CostDifficult to Implement
75 Matrix of Change Ideas High Impact Low Cost High Cost Low Impact Strive for high-impact , low-cost solutions.Translate high-cost solutions into low-cost alternatives.Low CostHigh CostTable exercise – flip chart sheet at each table…..copy matrix off slide and place ideas accordinglyLow Impact
76 Outline of “Snorkel” Review of Project Vision and Charter What do we know about……Propose a Design ChallengeStorytellingHow might we….?BrainstormingSelect top ideas (multi-vote)Prioritize ideas for developmentPlan prototypesEnactmentsDesign first series of tests
77 IDEO’s Design Principles Keep people informed throughout processValue people, time, and energyEnable learning and teachingGive people appropriate levels of controlFacilitate connections among people
78 EnactmentsCreate an enactment to illustrate an extreme future vision for your prototypeCreate storyline and buildRehearse and refinePresent to whole groupSelect elements and build on ideas
80 What could you do by next Tuesday? Think of some changes that you believe might enable you to get resultsThink of 1 changePlan your first PDSA’s
81 Small Scale Tests of Change on: One bay/wardOne day / shiftOne patientOne nurse
82 Action Planning Session Changes That Result in ImprovementModel for ImprovementWhat are we trying toaccomplish?How will we know that achange is an improvement?APWhat change can we make thatSDwill result in improvement?DATADSPImplementation of ChangeAASPDWide-Scale Tests of ChangeHunches Theories IdeasAPSDFollow-up TestsVery Small Scale Test
83 Next Steps Learning session 2 ACTION PERIOD Seek out a coach/facilitatorGet measures in placeTest the rounding process small scaleConnect with Tina Chambers/callsLearning session 2Is all about YOUWe want to hear your progress and see some results
84 Plan PDSA Cycle No 1 : General Wards 9 & Ward 4 Worksheet for Testing ChangeAim: To reduce Pressure Ulcer Incidence to zero by December 2012 (Overall goal you would like to reach) Every goal will require multiple smaller tests of changeDescribe your first (or next) test of change Person ResponsibleWhen to be doneWhere to be doneTest SSKIN Bundle on one patient on one ward next TuesdayJD&RWWeek commencing18th AprilWard 4 & Ward 9Plan List the tasks needed to set up this test of changePerson ResponsibleWhen to be doneWhere to be doneIdentify similar information from other TrustsDiscuss with teamIdentify a nurse and patient who are prepared to participate.Identify a suitable patient and seek their permissionJDW/C18TH AprilPredict what will happen when the test is carried out Measures to determine if prediction succeedsThe patient & nurse will understand the reason’s for the test and be happy to participateThe test will go wellThe patients’ risk of HAPU is reducedViews of patients and professionals will be sought
85 Do: Study: What happened? What did you learn? What surprised you? Act: What will you differently as a result of your test?What will your next test be?
86 You are this Hospital You are what people see when they arrive here. Yours are the eyes they look into when they’re frightened and lonely. Yours are the voices people hear when they are in the lifts and when they try to sleep and when they try to forget their problems. You are what they hear on their way to appointments that could affect their destinies and what they hear after they leave those appointments. Yours are the comments people hear when you think they can’t. Yours is the intelligence and caring that people hope they’ll find here. If you’re noisy, so is the hospital. If you’re rude, so is the hospital. And if you’re wonderful – so is the hospital. No visitors, no patients can ever know the real you, the you that you know is there — unless you let them see it. All they can know is what they see and hear and experience. And so I have a stake in your attitude and in the collective attitudes of everyone who works at Cooley Dickinson Hospital. We are judged by your performance. It is judged by the care you give, the attention you pay and the courtesies you extend. Thank you for all you are doing. CEO Cooley Dickinson Healthcare Org