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©Annette Bartley Consulting Limited 2011 Getting to Zero-Safer Care Improvement Programme Annette Bartley RGN BA MSc MPH Health Foundation/IHI Quality.

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Presentation on theme: "©Annette Bartley Consulting Limited 2011 Getting to Zero-Safer Care Improvement Programme Annette Bartley RGN BA MSc MPH Health Foundation/IHI Quality."— Presentation transcript:

1 ©Annette Bartley Consulting Limited 2011 Getting to Zero-Safer Care Improvement Programme Annette Bartley RGN BA MSc MPH Health Foundation/IHI Quality Improvement Fellow

2 09.00-09.15 Welcome & Introductions 09.15- 10.00 Background and Context Programme aims & objectives Links to other work 10.00-11.00 Overview of Quality Improvement Tools & techniques Measurement for improvement The role of local coaches 11.00-11.30 Refreshment break 11.30- 13.00 Team Presentations / Storyboard rounding 13.00-13.45 Lunch 13.45-15.00 The Snorkel – Generating Ideas from frontline staff 15.00-15.15 Refreshment break 15.15-16.15 Action planning and report out 16.15-16.30 Summary next steps and close Learning Session 1 Overview

3 ©Annette Bartley Consulting Limited 2011 Understanding the context of frontline care What’s good about it? What’s not so good? What could be improved?

4 ©Annette Bartley Consulting Limited 2011 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)

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 NHS III LIPs Productive Series NICE Quality Standards QUIPP & Safety Express Safer Patients Network (SPN) The Health Foundation (with IHI) CQUIN targets WHO World Alliance for Patient Safety Department of Health (DoH) High Quality Care for All IP&C CNO High Impact Changes

7 ©Annette Bartley Consulting Limited 2011 Will Ideas Execution Getting to Goal


9 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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

11 ©Annette Bartley Consulting Limited 2011 Where to begin Will Ideas Execution

12 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 Underpinning principles Transformational Leadership Safety & Reliability Patient and Family Centred Care Value-added care Teamwork and Vitality

15 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 Alignment -Harm Free Care

17 ©Annette Bartley Consulting Limited 2011 Prevention of Pressure Ulcers

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


20 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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)

23 ©Annette Bartley Consulting Limited 2011 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

25 ©Annette Bartley Consulting Limited 2011 ◦ 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 Change vs. Improvement Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress. W. Edwards Deming

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

27 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 Improvement requires a clear aim Measurement & Action

30 ©Annette Bartley Consulting Limited 2011 AIM 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

31 Developing a systems-based approach to the prevention of hospital acquired pressure ulcers Risk Identification Communication of Risk status Risk Assessment Appropriate preventative strategy implemented Evaluation of outcome What will success look like?

32 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 “In God we trust. All others bring data.” W. E. Deming

36 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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)

39 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 12 34 56 (3) 78 (1) 9101112 131415161718 1920 (1) 212223 24 (1) 25 (1) 26 Days since last... 2728 (1) ___ days 293031

43 ©Annette Bartley Consulting Limited 2011 Real Time Data for improvement – Process

44 ©Annette Bartley Consulting Limited 2011 It’s time… A little less conversation a little more action

45 ©Annette Bartley Consulting Limited 2011 Getting it right Co-ordinating Care

46 Health Care Processes 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 Current - Variable, lots of autonomy not owned, poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels Terry Borman, MD Mayo Health System

47 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 1.Opening key words – managing up 2.Perform scheduled tasks 3.Address the 3 p’s of pain, potty? position (SKIN Bundle)(toileting), and 4.Assess comfort needs 5.Environmental assessment 6.Closing key words 7.Explain when you or others will return 8.Document the round on the log

50 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 Tools – Rounding Log

52 ©Annette Bartley Consulting Limited 2011 Tools – Badge Card

53 ©Annette Bartley Consulting Limited 2011 Tools – Accountability Tool

54 Rounding commenced

55 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 57

58 ©Annette Bartley Consulting Limited 2011 What they are not… 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 Patient &family centred care

61 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 The Snorkel

65 ©Annette Bartley Consulting Limited 2011 Fostering Creativity and Brainstorming?

66 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 Resources for “Snorkel”

69 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 Difficult to Implement Easy to Implement Low CostHigh Cost Place concepts in matrix. Strive for easy, low- cost solutions. Translate high-cost solutions into low-cost alternatives.

75 Matrix of Change Ideas Low Impact High Impact Low Cost High Cost Translate high-cost solutions into low- cost alternatives. Strive for high-impact, low-cost solutions.

76 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 IDEO’s Design Principles 1. Keep people informed throughout process 2. Value people, time, and energy 3. Enable learning and teaching 4. Give people appropriate levels of control 5. Facilitate connections among people

78 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 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 ©Annette Bartley Consulting Limited 2011 Small Scale Tests of Change on: One bay/ward One day / shift One patient One nurse

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

83 ©Annette Bartley Consulting Limited 2011 Next Steps 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 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 TuesdayJD& RW Week commen cing 18 th 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 1)Identify similar information from other Trusts 2)Discuss with team 3)Identify a nurse and patient who are prepared to participate. 4)Identify a suitable patient and seek their permission JDW/C 18 TH 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 Act: What will you differently as a result of your test? What will your next test be? Do: Study: What happened? What did you learn? What surprised you ?

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 ©Annette Bartley Consulting Limited 2011 Thank You! Questions?

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