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
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
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?
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)
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
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.
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.
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
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
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 ?
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