1. Supporting NHS Wales to Deliver World Class Healthcare AWSSIC Year Two Learning Session One 21 October 2009

2. Slide 2 Carl James Head of Performance Management Policy Development, Waiting Times and Emergency Care Department for Health and Social Services WAG Dr Alan Willson Director of Research and Development, NLIAH Joint Director of 1000 Lives Campaign Intelligent Targets

3. Slide 3 Performance Improvement for Patients A View from the Top ?? Minister view clear about need to improve quality of care Driven by clinicians and healthcare professionals Consensus that more focus /pace required Current The Dark Side ‘Annual Operating Framework’ Nationally set targets Top down improvement Quality vs performance vs finance

4. Slide 4 It has achieved improvement ! But…… Not sensible or clinically credible Improvement targets not owned by all Single points of complex pathways – not representative Perverse incentives Limited change which are not sustainable Fact, perceptions and myths

5. Slide 5 Self governing organisations Patient quality at the centre of design and delivery Quality focused improvement targets Across care pathways Clinically driven and owned Will.. Improve outputs, outcomes and patient experience Deliver sustainable change in a complex system Somewhere over the rainbow ?

6. Slide 6 Quality Reduction of waste (delays, defects, over- production, rework) Reduction of variation (against evidence base / across services/across Wales) Reduction of harm What we need is a common language ?

7. Slide 7 And a common approach ! Intelligent Targets Objectives Complete care pathway Critical success / ‘Wow’ factors Evidence based Outcomes measures (effectiveness, safety, experience) Approach 4 pilots (cardiac, stroke, unscheduled care, mental health) National Steering Group supported by 4 core groups Driven and made up of healthcare professionals, policy leads Facilitated by NLIAH Success of stroke collaborative and 1000 Lives Campaign

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9. Slide 9 Wales stroke audits over 5 years -what is worse? Brain scan in 24 hours – 60% to 38% OT assessment - 62% to 50% Home visit before discharge – 80% to 53% -what is better? Aspirin started – 72% to 76% MDT goals agreed – 58% to 70%

10. Slide 10 Improve the reliability of care in Wales Raise the standards of care in Wales What are we actually trying to do?

11. Slide 11 A Quote Although clinicians setting targets is the way forward, how do we re-educate them to move away from end line inspection to on line inspection? They have grown up in organisations which review complaints, undertake audit, reflect on research….which all have their place, but amazingly with such a captured audience ‘the patient’ they fail miserably to monitor, measure and improve quality at the bedside. Can you imagine a world whereby all staff were involved in quality questioning….I would predict a stepped change in complaints!

12. Slide 12 The Intelligent Targets Approach Focus on process of change Use expert groups for subject knowledge Use model for change as a standard Greenhalgh criteria

13. Slide 13 Greenhalgh Criteria It must have clear relative advantage It must have compatibility with the user’s values and ways of working Complexity must be minimised Users will adopt more readily if innovations allow trialability There must be observability, that is it must be seen to deliver benefit Reinvention is the propensity for local adaptation

14. Slide 14 An evidence-based model for producing clinical change The Model for Improvement Agreed process changes (care pathways and driver diagrams) Outcome and Process measures Appropriate Performance Management Support for improvement (will/ ideas/ execution) Tools- data handling, driver diagrams, collaborative learning

15. Slide 15 Model for Improvement

16. Slide 16 An example from another setting Acute MI Care in US Aspirin at discharge ACEI for LVSD Beta-blocker at arrival Beta-blocker at discharge Door to lytic Door to PCI Smoking cessation advice Composite and all-or-none scores Survival rate/index Aspirin at arrival

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18. Slide 18 Strategies –Level 1 “Intent, vigilance, hard work” Standardized protocols Feedback Training Checklists

19. Slide 19 Strategies –Level 2 “Redesign the system – don’t rely on checking” Decision aids and reminders built into the system Automation Evidence as the default Scheduling Connection to habits

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21. Slide 21 Experience from Year One AWSSIC Method makes sense Measurement and reliability are new concepts Team work is encouraged across pathway Connections with management need work We are seeing change and so are patients!

22. Slide 22 Respecting measurement DomainExamples Uptake (organisational conditions Identified management lead Identified clinical champion Intranet sign up Data submitted Teams trained Local communication strategy in place Process change (Intelligent Targets) Bundle compliance Uptake of new practice (specific to driver diagram) Outcome change (consequence of process) Reduced morbidity Reduced mortality Reduced dependency Reduced hospital stay

23. Slide 23 Taking this forward Stroke as a starter Four clinical areas Agree driver diagrams Design and prove spreadsheet Incorporate in Annual Operating Framework 2010/11 Support learning and implementation 5 year rolling programme

24. Slide 24 Improved quality of care for patients Clinically owned / evidence based improvement Sustainable services A common language ? Reduction of waste Reduction of variation Reduction of harm What's in it for us ?