1. Integrating clinical audit with quality improvement - a model of delivery from Aneurin Bevan University Health Board Rachel Fletcher MSc ABCi Lead – Project Support Team 15 th October 2013 HQIP ‘Ensuring Safety, Driving Improving’ Conference

2. Two journeys meet in the middle Top down 1000 Lives Campaign 1000 Lives Plus Programme Learning from Jonkoping, Ko Awatea, Kaiser Permanente etc Building Capacity for Quality Improvement  IQT  Health Board Faculties ABUHB commitment to QI Bottom Up Clinical Audit Safer Patients Initiative 1000 Lives Campaign 1000 Lives Plus Programme Shift away from Clinical Audit towards Quality Improvement

3. What did we learn? Evidence based introduction of change - not Spray’n’Pray! Effective way to measure improvement realtime – SPC Need to support clinicians to measure process/outcome 2009/10 ABHB Clinical Audit Annual Report 248 Clinical Audits 61% Audits led to agreed actions/shared learning 28% re-audits – difficult to assess actual improvements 1000 Lives - 143 series of data 61% statistical improvement in outcome measures 64% statistical improvement in process measure

4. 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? The Model for Improvement ActPlan StudyDo Model for Improvement Measurement a key component Employs Statistical Process Control Techniques Measurement

5. Audit Posters International Forum for Quality & Patient Safety 2013

6. Process & System Improvement Posters International Forum for Quality & Patient Safety 2013

7. Clinical Audit often aggregates data Before and After

8. SPC plots data over time as Runcharts or Control Charts

9. What did we do? ABUHB Board Q&PS Committee development session – priorities set National priorities 1000 Lives Plus Divisional priorities  highest risks,  patient experience,  focus on demonstrable improvement Staff engagement workshops Visits to all Audit Leads Restructured workloads New job descriptions Staff training

10. Clinical Effectiveness Group chaired by Medical Director responsible for ensuring: Overview of NCA&OR Plan at ABHB Clinical Lead for each audit Register of National Audits Feedback re: each audit to CEG  Priority audits full presentation  Other audits via feedback template  Timetable of feedback devised Learning and Action as a result of audit Annual Report 2012/13 Welsh Government NCA&OR Advisory Group visit National Clinical Audit and Outcome Review Plan – ABHB progress

11. 1000 Lives Plus Coordinators supporting teams: Acute Stroke Stroke Rehabilitation Life After Stroke Chronic Heart Failure (CHF) Hospital Acquired Thrombosis (HAT) Leadership Walkrounds Transforming Maternity Services Mouthcare Enhanced Recovery After Surgery (ERAS) Catheter Associated Urinary Tract Infection (CAUTI) Theatres Community Falls Through: Care Metrics & Fundamentals of Care Supporting clinicians in gathering, collation, analysis, interpretation, reporting and feeding of progress and data Liaising with agencies to gather routine data eg. WHAIP, 1000 Lives central team Regular feedback to clinical teams High Level Data to Board as part of QI Report Mortality Reviews GTT Reviews

12. Board Data Frontline data Directorate data Divisional data Support & Leader- ship for work Data to Directorate Quality Imp./Audit Meetings Locally held 1000 Lives spreadsheets/audits Reports to Divisional Quality & Patient Safety Groups QI Report of 1000 Lives measures to Q&PS Committee Q&PSIMDept Support for data reports 1000 Lives Data - Aims

13. Divisional QI Projects Working with divisions to set up Quality Improvement Programmes Eg. O&G QuIP Programme, priorities for division, QuIP teams leading each project Aim to incorporate divisional priorities, national audits and 1000 Lives work But…not all plain sailing!

14. Bringing together expertise from across the health board Clinicians Improvement managers Clinical audit To support divisions with their QI programmes 5 arms – ABCi Project Support Team Linking with Cardiff University – Mathematical Modelling Meeting new people and learning from each other Developing a confident Project Support Team Learning from others – shadowing Improvement Leads to see techniques in practice Involvement in larger service level change Silver IQT Training Supporting smaller QI projects – ie. Turning a Clinical Audit into a QI Project Linking QI methods with National Audits Project Support Team

15. Bringing a framework and methodologies for clinical teams to improve the services they deliver Helping make improvement part of everyone’s job The process will help teams understand clinical outcomes, patient experience, efficiency and how they spend their money Thinking about a whole system Best evidence and practice Aim of ABCi

16. Functions Developing and supporting leaders Quality Improvement Training (IQT) ABCi Project Support Team – supporting divisional QI projects/programmes Innovation and knowledge management Modelling Unit

17. Structure Working with divisions to develop and support a programme for improvement Identifying improvement champions within each Division Having an accountable link back to ABCi Allocating measurement and mathematics resource to each division

18. Some final thoughts… Prof. Nick Black Call for ‘Quality’ not ‘Audit’ Departments [HQIP Clinical Audit for Improvement Conference. London Feb 2013] National Advisory Group for Clinical Audit & Enquiries (DOH) Consultation on Future of Audit staff in Trusts - Proposals include: Distinguishing between quality assessment and quality improvement Quality Departments integrating clinicians, managers and clinical audit staff Training in technical skills such as Improvement Science and Behavioural Skills

19. Real-time monitoring of performance over time. Interventions for change are implemented and their effects assessed almost immediately QI – Model for Improvement SPC Snapshot in time of overall performance. Checks that standards are maintained and improved where necessary Re-Audit Clinical Audit Standard A  Standard B Standard C Snapshot in time of overall performance compared to evidence based standards. Highlights where there are deficiencies in practice Integrating Clinical Audit with QI The Clinical Audit Gap Clinical audit doesn’t give us methods to make change Clinical Audit doesn’t measure during the process of change

20. Thankyou Rachel.fletcher@wales.nhs.uk Twitter @rachelnfletcher Follow on Twitter @ABCiAb

21. On your tables please discuss: How can you integrate the national clinical audit/local audit with Quality Improvement Methodology? How does your organisation set priorities for the use of Clinical Audit/Quality Improvement resources? What do I need to do to change my practice in the light of what I have heard today?