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Getting to Zero-Safer Care Improvement Programme

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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 MPH Health Foundation/IHI Quality Improvement Fellow

2 Learning Session 1 Overview
Welcome & Introductions Background and Context Programme aims & objectives Links to other work Overview of Quality Improvement Tools & techniques Measurement for improvement The role of local coaches Refreshment break Team Presentations / Storyboard rounding Lunch The Snorkel – Generating Ideas from frontline staff Refreshment break Action planning and report out Summary 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

5 The Reality in Practice

6 How do we make sense of all the expectations & bring the work into a coherent whole
Health Foundation Safer Communities National Patient Safety Agency (NPSA) Safety Alerts Matching Michigan CNO High Impact Changes QUIPP & Safety Express NHS III LIPs Productive Series Safer Patients Network (SPN) The Health Foundation (with IHI) WHO World Alliance for Patient Safety Over 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. NICE Quality Standards Department of Health (DoH) High Quality Care for All IP&C CQUIN targets

7 Getting to Goal Will Ideas Execution

8 Anita Tucker and Steve Spear describe how nurses spend the majority of their time being interrupted and hassled We 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 care 8

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 individual More than a change Develop new habits of mind What is transformation and what does it mean for ach of you and for the wider community?

11 Where to begin Will Ideas Execution

12 Programme Aims Alignment with Safety Express
To reduce the incidence of Avoidable Hospital /Community Acquired Pressure Ulcer Reduce of Falls (falls with harm) Reduce Catheter Associated Urinary Tract Infections (CAUTI) Prevention of Venous Thromboembolism ( VTE)

13 Programme overview

14 Underpinning principles
Transformational Leadership Safety & Reliability Patient and Family Centred Care Value-added care Teamwork and Vitality

15 Patients as partners “ If quality is to be at the heart of everything we do, it must be understood from the perspective of patients.”

16 Alignment -Harm Free Care

17 Prevention of Pressure Ulcers

18 ! Transforming Care at the Bedside framework
Spread the Learning and celebrate the successes 4 4 4


20 Pressure Ulcers The “Case for Change”
National Focus on Patient Safety I in 10 patients harmed by what we do Poor Public Perception of Care Impact of financial cutbacks Pressure Ulcer Incidence 1 in 5 As 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 Facts Pressure sores are an increasing problem that affect thousands of people unnecessarily every year.. They are painful, debilitating and can be life threatening The 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 care Treatment with respect and dignity Involvement Doctors Nurses Cleanliness Pain control

24 Methods and Tools Quality Improvement methodology consists of many of tools and techniques. Shown here are the one’s we feel are necessary to all QI ventures Asking the three simples questions on The MFI Starting with small tests of change with sequential building Then moves from the testing to implementing, spreading and sustaining the improvement Monitoring of data over time Using data to learn and to improve

25 4/14/2017 Change vs. Improvement Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress. W. Edwards Deming We must become masters of improvement We must learn how to improve rapidly We must learn to discern the difference between improvement and illusions of progress MCPP Healthcare Consulting

26 The Lens of Profound knowledge
Deming Appreciation of a system Theory of Knowledge Psychology C Q I Aims or values Understanding Variation

27 Quality Improvement Methods /Tools
The Model for Improvement The Science of Reliability Driver Diagram Change Package Lean/5S Safety Cross/ Safety Thermometer SSKIN 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 SMART Specific Measurable Achievable Realistic Timely Goals 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 ulcers Risk Identification What will success look like? Risk Assessment Communication of Risk status Appropriate preventative strategy implemented Evaluation of outcome

32 The “Case for Change” National Focus on Patient Safety
I in 10 patients harmed by what we do Public Perception of Care Impact of financial cutbacks Strong 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=Process The method by which health care is provided O=Outcome The consequence of the health care provided Avedis Donabedian Physician

37 Research vs Measurement for Improvement

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 month Be careful about over-doing process measures for monthly reports Make use of available data bases to develop the measures Integrate data collection for measures into the daily routine Plot 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 measure A balanced set of five to eight measures will ensure that the system is improved Balancing 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 measures Incidence ( count on safety cross) Days between events Process measures Percent Compliance with risk assessment Percent Compliance with process ( bundle) Percent compliance with Intentional Rounding tool Balancing measures Patient Experience Staff satisfaction Length of Stay Complaints Staff turnover /Sickness rates Budget implication

42 Visual Measurement Days since last... ___ days 1 2 3 4 5 6 (3) 7 8 (1)
9 10 11 12 13 14 15 16 17 18 19 20 (1) 21 22 23 24 (1) 25 (1) 26 Days since last... 27 28 (1) ___ days 29 30 31

43 Real Time Data for improvement – Process

44 It’s time… A little less conversation a little more action

45 Getting it right Co-ordinating Care
Multitude of Activities Confronting Hospitals Creates 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 any feedback for improvement, constantly altered by individual changes, performance stable at low levels Desired - variation based 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 - variation Terry Borman, MD Mayo Health System 46

47 Intentional Rounding The Evidence
The Studer Group Alliance for Health Care Research 38% Reduction in Call Lights 12 point mean increase in Pt Satisfaction 50% reduction in patient falls 14% reduction in pressure ulcers Flaws 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 tasks Rounding with purpose- linked to an aim 8 key behaviors Opening key words – managing up Perform scheduled tasks Address the 3 p’s of pain, potty? position (SKIN Bundle)(toileting), and Assess comfort needs Environmental assessment Closing key words Explain when you or others will return Document the round on the log

50 OMHS Intentional Rounding - wins
59% reduction in Pressure ulcers 54% 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

51 Tools – Rounding Log

52 Tools – Badge Card

53 Tools – Accountability Tool

54 Rounding commenced

55 Intentional Rounding -Benefits
Provide staff with better control of their time Improved outcomes / promote safety Results Increase Patient Satisfaction Decreases anxiety Increase trust and give sense of comfort Increase Employee Satisfaction

56 Additional Benefits Centred on patients/Catches all
Provides a quality assurance framework for nursing care Helps to evidences what nurses do Helps demonstrates the impact on patient outcomes Potential to impact on the bottom line

57 It is the nature of systems that smaller systems are embedded in bigger systems
57 57

58 ‘PDSA’s' ‘test’ a proposed change
What they are not… A radical change to a system /process Full blown trust-wide implementation Mini projects (monumental proportion) Top down directives ‘PDSA’s' ‘test’ a proposed change

59 Paper Plane Exercise Aim – To design a paper plan that will fly the longest distance Assign a design team Assign someone to assemble the plane Assign 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, and providers 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 volunteers Willing to play a key role locally as coaches /facilitators Support participants and help to accelerate momentum and the progress They will be the links between you and the programme team

62 Storyboard rounding Split up into your teams
Identify a space to display your storyboard Select at least one member to present the findings Everyone else will rotate around the teams Approximately 7-8 mins to describe your team/aspirations/learning from pre-work Bell will sound and teams will rotate to the next space

63 Harvest Identify three things you learnt during the rounding
Could be meeting new people Harvesting Ideas from another team Results/learning from their pre-work

64 The Snorkel

65 Fostering Creativity and Brainstorming?

66 Methods for Generating New Ideas
Change Concepts Using Technology Critical Thinking IDEO Brainstorming Metaphorical Thinking Observation Provocation Prototyping Idealized Design

67 Innovation and Work Redesign

68 Resources for “Snorkel”

69 Outline of “Snorkel” Review of Project Vision and Charter
What do we know about …. Propose a Design Challenge Storytelling How might we….? Brainstorming Select top ideas (multi-vote) Prioritize ideas for development Plan prototypes Enactments Design first series of tests

70 Storytelling In lieu of doing actual observations, use storytelling to “observe” actual experiences Recall 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 example Tell 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 ideas go for quantity – want more than 500 ideas defer judgment be visual – draw pictures one conversation at a time build on ideas of others stayed 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 exercise Use 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 biggest impact 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 between Report 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 Cost High Cost Difficult 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 Cost High Cost Table exercise – flip chart sheet at each table…..copy matrix off slide and place ideas accordingly Low Impact

76 Outline of “Snorkel” Review of Project Vision and Charter
What do we know about…… Propose a Design Challenge Storytelling How might we….? Brainstorming Select top ideas (multi-vote) Prioritize ideas for development Plan prototypes Enactments Design first series of tests

77 IDEO’s Design Principles
Keep people informed throughout process Value people, time, and energy Enable learning and teaching Give people appropriate levels of control Facilitate connections among people

78 Enactments Create an enactment to illustrate an extreme future vision for your prototype Create storyline and build Rehearse and refine Present to whole group Select elements and build on ideas

79 Enactments

80 What could you do by next Tuesday?
Think of some changes that you believe might enable you to get results Think of 1 change Plan your first PDSA’s

81 Small Scale Tests of Change on:
One bay/ward One day / shift One patient One nurse

82 Action Planning Session
Changes That Result in Improvement Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? A P What change can we make that S D will result in improvement? DATA D S P Implementation of Change A A S P D Wide-Scale Tests of Change Hunches Theories Ideas A P S D Follow-up Tests Very Small Scale Test

83 Next Steps Learning session 2 ACTION PERIOD
Seek out a coach/facilitator Get measures in place Test the rounding process small scale Connect with Tina Chambers/calls Learning session 2 Is all about YOU We want to hear your progress and see some results

84 Plan PDSA Cycle No 1 : General Wards 9 & Ward 4
Worksheet for Testing Change Aim: 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 change Describe your first (or next) test of change             Person Responsible When to be done Where to be done Test SSKIN Bundle on one patient on one ward next Tuesday JD& RW Week commencing 18th April Ward 4 & Ward 9 Plan                        List the tasks needed to set up this test of change Person Responsible When to be done Where to be done Identify similar information from other Trusts Discuss with team Identify a nurse and patient who are prepared to participate. Identify a suitable patient and seek their permission JD W/C 18TH April Predict what will happen when the test is carried out         Measures  to determine if prediction succeeds The patient & nurse will understand the reason’s for the test and be happy to participate The test will go well The patients’ risk of HAPU is reduced Views 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

87 Thank You! Questions?

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