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Quality Improvement and Transformation

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Presentation on theme: "Quality Improvement and Transformation"— Presentation transcript:

1 Quality Improvement and Transformation
Annette Bartley RGN BA (Hon) MSc MPH Director of the Safer Patient Network Health Foundation/ IHI Fellow Co-facilitator of CHAIN QI sub-group 4/14/2017 © Annette Bartley Consulting Limited

2 Why do we need to improve?
Despite a decade of government initiatives to make healthcare safer one in ten patients continue to be harmed as a result of hospital treatment, . Avoidable harm! As this table show healthcare is more hazardous than sports such as mountain climbing and bungee jumping. Patient Safety needs to be seen as the number one priority within healthcare organisations. The “first do no harm” principle South Central is to be commended for recognising the importance of patient safety and for making it the priority across the region It is important to recognise however that safety is a key component in the much broader quality improvement agenda 4/14/2017 ©Annette Bartley Consulting Limited

3 The Centers for Medicare & Medicaid Services
QI is a "set of related activities designed to achieve measurable improvement in processes and outcomes of care. Improvements are achieved through interventions that target health care providers, practitioners, plans, and/or beneficiaries."6,7 The Centers for Medicare & Medicaid Services Quality Improvement aims at “raising the bar” taking performance to a new improved level Patient Safety aims at raising existing standards of care improving safety and process that already exist The focus need be on both ends 4/14/2017

4 Institute of Medicine Aims
Safe (no needless deaths) Timely (no unwanted waiting) Efficient (no waste) Effective (No needless pain or suffering) Patient and family centred (no helplessness) Equitable (for all) IOM= Crossing the Quality chasm 2001 (IHI) 4/14/2017

5 First do no harm… Fundamentals of patient safety
Prevention Detection Mitigation 4/14/2017

6 The Reality in Practice

7 System-Level Redesign
Every system is perfectly designed to achieve exactly the results it gets. New levels of performance can only be achieved through dramatic system-level redesign. 4/14/2017

8 “Quality improvement begins with love and vision. Love of your patients. Love of your work. If you begin with technique, improvement won’t be achieved.” Donabedian was a pioneer in the field of health-care quality, and he developed a basic framework in which to think about quality-improvement efforts. Donabedian defined the health-care triad of structure, process and outcome A. Donabedian, M.D 4/14/2017

9 Bringing the Work of Many Initiatives into a Coherent Whole
National Patient Safety Agency (NPSA) Safety Alerts Matching Michigan Health Foundation Safer Communities CNO High Impact Changes The Patient Safety First Campaign NHS III LIPs Productive Series QIPP 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 CMO England VTE 4/14/2017

10 From what… to how A little less conversation a little more action

11 Deming’s Thoughts on Transformation
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 4/14/2017

12 Where to begin Will Ideas Execution 4/14/2017

13 Executive Perceptions vs. Frontline Perceptions:
Executives overestimate: Teamwork Climate 4X Safety Climate 2.5X Executive Confidence vs. Executive Accuracy: -Often wrong but rarely in doubt… -Currently no incoming data-streams -Halo Effects -Frontline data fills the gap 13

14 4/14/2017

15 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 4/14/2017 Terry Borman, MD Mayo Health System 15

16 Reliability Post office Ritz Carlton Mc Donald’s Virgin Flights

17 New 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 4/14/2017

18 The Model for Improvement...
Aims What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements we seek ? The three fundamental questions for improvement Measurement Ideas, evidence, hunches, other people etc. Act Plan Study Do The fourth question: how to make changes 4/14/2017 Langley, Nolan et al 1996

19 Repeated Use of the PDSA Cycle
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 Implementation of Change P A A S P Wide-Scale Tests of Change D Hunches Theories Ideas A P S D Follow-up Tests Very Small Scale Test 4/14/2017

20 Small Scale Tests of Change on:
One clinic One patient One doctor One nurse One day / shift 4/14/2017

21 Where do I begin? Hunches & Theories Gap in knowledge
Set about testing your theory Cause & Effect 4/14/2017

22 Steps to reliable care Do the acid test? Segment your population
Design an articulated process goal, Agree a clear outcome goal connected to the process with some supporting evidence. Use the prevent, detect, mitigate theoretical design to understand failures and to learn how to redesign Design your first test of change Determine the tempo of change 4/14/2017 22

23 Improvement requires a clear aim
Measurement & Action 4/14/2017

24 Process Eyes Make the process for preventing Pressure Ulcers (&Falls) visible to ALL Measure it -so we can ‘see’ if it is adhered to and effective Make it easy for others to do the right thing (simple checklists, reminders) The right process with high % compliance WILL influence outcomes

25 4/14/2017

26 4/14/2017

27 Days without a hospital acquired pressure ulcer (ABM LHB Wales)
Clear Aim Engaged Team Simple measures-just enough data Tests of change Results 638 4/14/2017

28 Patients as partners “ If quality is to be at the heart of everything we do, it must be understood from the perspective of patients.” 4/14/2017

29 Nothing about me without me

30 The Value of Networks “Good Networks are horizontal partnerships which value professional expertise and mutual learning. In doing so, they overcome hierarchy and create connections between different levels of the system. They are support structures for improving the quality of care and patient safety ” 4/14/2017

31 How can CHAIN assist the Allied Health Professions?
Motivate and inspire Making Connections between individual improvers Empowering professionals to use evidence Sharing knowledge and experience Tools and Techniques for Improving practice 4/14/2017

32 Research / online communities
Lurking Linking Learning Leading When developing a community that will not be meeting on a regular basis the dynamics are very different to one that meets regularly. Seeley in his research on development of on-line communities describes four stages of learning which I believe can be applied to developing communities of practice: The 4 L’s Lurking – Folks attend calls/meeting but don’t actively engage – they ‘lurk’ around the edges of the community Linking- These folks then start to make connections and links between the work they are doing and the work of the community and to forge links with others in the community Learning- Once immersed into the community they truly begin to learn Leading- Strong connections are made , the learning is in progress and the application of learning and leading others in this work begins A shift from passive to active participation John Seeley-Brown 4 L’s 4/14/2017 32

33 Distributed leadership Marshall Ganz
“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

34 The Politics of hope Get organised! Find your carpenters!
Provide them with the tools! Stand back as they get going! 4/14/2017 34

35 Michelangelo’s Thoughts on Transformation
“In every block of marble I see a statue as plain as though it stood before me, shaped and perfect in attitude and action. I have only to hew away the rough walls that imprison the lovely apparition to reveal it to the other eyes as mine see it.” “I saw the angel in the marble and carved until I set him (her) free.” .... Michelangelo “In every block of marble I see a statue as plain as though it stood before me, shaped and perfect in attitude and action. I have only to hew away the rough walls that imprison the lovely apparition to reveal it to the other eyes as mine see it.” Michelangelo 4/14/2017

36 Questions? Hey… what’s a mountain goat doing way up here in a cloud bank?

37 4/14/2017

38 Managing improvement in the context of multidisciplinary teams
What does this mean to you? Does anyone have experience/examples of working within an effective team? What are the key characteristics of an effective team? What about working in an ineffective team? What might that look like? What do teams need to enable them to improve the quality of care? The sum of the whole is greater than the parts Shared 4/14/2017

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