The Model for Improvement Kevin Gibbs

1. Redesigned care processes 2. Effective use of information technologies 3. Knowledge and skills management 4. Development of effective teams 5. Coordination of care across patient conditions, services and settings over time 6. Use of performance and outcome measurement for continuous quality improvement and accountability Crossing the Quality Chasm. US Institute of Medicine Convince people there is a problem 2. If you do it, will it work? 3. Data collection and monitoring 4. Project goals must be realistic and achievable 5. Communication to staff and support 6. Project must be owned, common goals 7. Leadership 8. Incentivising participation / staff motivation 9. Securing sustainability 10. Side effects of change - counterbalancing Analysis of Health Foundation improvement programmes Challenges in “Improvement” Adapted from: BMJ Qual Saf 2012;1-9 doi: /bmjqs link) link

HOW DO WE KNOW HOW WE ARE IMPROVING? The Model for Improvement

Fundamental questions Set aims Time-specific and measurable Establish measures Does a specific change actually lead to an improvement Selecting changes Ideas for change

Test changes Test in the real world setting Most common model comes from Industry but widely used in health care PDSA cycle  Plan it  Try it  Observe the results  Act on what has been learnt

A method to test ideas safely  Starting small and building on the results of the cycle  With each cycle you gather more knowledge to help make the next improvement  Allows measurement of the effect of the change over time PDSA cycle Plan – Do – Study - Act < /2008/01/ /3

Example Diabetes: Planned visits for blood sugar management. Plan: Ask one patient if he or she would like more information on how to manage his or her blood sugar. Do: Dr. J. asked his first patient with diabetes on Tuesday. Study: Patient was interested; Dr. J. was pleased at the positive response. Act: Dr. J. will continue with the next five patients and set up a planned visit for those who say yes.

It is important to document these changes and the decisions made

Repeated PDSA cycles Learning over time Hunches Theories Ideas Changes that Result in Improvement

“All improvement will require change but not all change will result in improvement” Langley G, et.al. The Improvement Guide. 2 nd edn. Pub: Josey-Bass ISBN HOW WILL WE KNOW THAT OUR CHANGE IS AN IMPROVEMENT?

“ In God we trust, all others bring data” W Edwards Deming

Measurement for Research Measurement for Learning and Process Improvement PurposeTo discover new knowledgeTo bring new knowledge into daily practice TestsOne large "blind" testMany sequential, observable tests BiasesControl for as many biases as possible Stabilize the biases from test to test DataGather as much data as possible, "just in case" Gather "just enough" data to learn and complete another cycle DurationCan take long periods of time to obtain results "Small tests of significant changes" accelerates the rate of improvement Measurement for improvement From: Institute for Healthcare Improvement <

1. Outcome measures How the overall system is improving - the end result 2. Process measures How the individual parts of the system are working 3. Balancing measures What happens elsewhere in the system when you make the change - other consequences Consider sampling e.g. 5 patients per ward per week Levels of measurement

Graph your results These can be statistical or visual Annotate your results with your changes to see their influence Run charts

AUG non-critical delayed (any drug not given within 90mins but given within 12 hours) medication taken out of data collection. JAN/FEB 2013 Understaffing (nursing) and excessive bed pressure? SEPT 2012 Interventions - Feedback form introduced - Departmental education MARCH - MAY 2013 New drug cupboards installed JULY 2013 missed doses campaign 1. Re-launch magazine rack 2. New drug bulletin 3. Divisional safety team support SEPT 2013 – More specific strategy to engage band 5 nurses Jan 14 New medical model of care NO DATA Feb Magazine rack with bike light 2. Red dots re-launched 3. Drug Bulletin Issue2 4. Spread to ward 12 and 4

SPREAD AND SUSTAIN

Spread is the process of taking a successful implementation process from a pilot unit or pilot population and replicating that change or package of changes in other parts of the organisation or other organisations. This should draw on your experiences from the PDSA-testing Resources needed Tasks and procedures Working with people to help them adopt and adapt the change <

Testing and spreading Testing: 1  5  10  spread One patient then 5 patients then 10 patients then a ward… At the end of each ‘try’ go into a huddle with those trying out the change What worked What didn't work Change as necessary Test again tomorrow Document decisions

Identify a leader who is responsible for the spread Be able to remove obstacles Identify the target population for the spread Which wards / units etc. What did you learn from the pilot areas(s) where you tests your change? What key messages will explain the new system / idea to the target population? Patient stories / Show results / Individual testimonies from those who have benefitted from the change Good communication Spreading the change

IN PRACTICE

Driver Diagram

Driver Diagram (Example)

Local help West of England Academy Step One (Understanding) provides all staff with access to well-established online training in fundamental QI tools. Step Two (Delivering) provides all staff with a unique opportunity to use a BMJ Quality licence; free of charge! It will give you access to a BMJ Quality mentor to provide expert advice for delivering a QI project, and enable you to have your project published on the BMJ Quality website. Step Three (Leading) keep an eye out on our website for more information on our Improvement Coaches programme and how you can apply for future cohorts. Uses a QI Passport stamped as you progress through the steps The pathway is flexible, recognition of previous work can fulfil steps 1-2 Existing training endorsed by line manager Can then progress to the step most appropriate to your needs Training is recognised across West of England AHSN organisations, giving recognition any cross organisational working

< w.nhsiq.n hs.uk/ Further information < < Measuring for improvement West of England Academy: The improvement journey < development/improvement-resources-and-tools/the- improvement-journey /