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 systems57 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? abartley@ihi.org