Whole System Quality Measures in an Integration World Dr Andrew Longmate National Clinical Lead for Patient Safety The Quality Unit Scottish Government Integration

Don Berwick’s Ethics of Improvement 1.Professionals have a duty to help improve the systems in which they work 2.Leaders have a duty to make 1) logical, feasible and supported 3.No excuses for inaction on 1) and 2) are acceptable 4.The duty to improve encompasses safety, effectiveness, patient centredness, timeliness, efficiency and equity. This requires the continual reduction of waste. 5.Those who educate professionals have a duty to prepare them for this improvement work.

Summary 10. There are learning points from SRFT that could be usefully applied across Scottish health boards to accelerate our journey towards the 20:20 vision. Scottish Government has the opportunity to further accelerate progress towards the 20:20 vision by clarifying the expectation that Health Boards integrate the delivery of person centred, safe and effective care at the frontline ensuring our national programmes are designed to drive and support integration ensuring that Territorial Health Boards are directed to build and apply local infrastructure and capability to drive sustainable quality improvement

Lessons for transformational change 1.In order to sustain transformational change we need to move from a burning platform (fear based urgency) to a burning ambition (shared purpose for a better future) 2.We need to articulate personal reasons for change as well as organisational reasons 3.If the fire (the compelling reason) goes out, all other factors are

@helenbevan Police Inspector and systems thinker

@helenbevan Purpose Obfuscation O-meter Police Inspector and systems thinker

@helenbevan Police Please catch the person who burgled my house input We can only afford another 4.3 burglaries per day for the rest of the month other wise we will miss the reduction target what the machine Police Inspector and Systems Thinker

@helenbevan Education I want my child to learn input Schools should be ranked in league tables according to the proportion of students who attain results at Grades A - C Schools should be ranked in league tables according to the proportion of students who attain results at Grades A - C what the machine Police Inspector and Systems Thinker

@helenbevan Healthcare Help me get better input A 95 th percentile of A and E patients must be admitted, discharged or transferred within 4 hours of arrival in the department what the machine Police Inspector and Systems Thinker

Drivers of extrinsic motivation create focus & momentum for delivery Intrinsic motivators connecting to shared purpose engaging, mobilising and calling to action motivational leadership build energy and creativity System drivers & incentives Payment by results Performance management Measurement for accountability

Internal motivators connecting to shared purpose engaging, mobilising and calling to action motivational leadership build energy and creativity Drivers of extrinsic motivation System drivers & incentives Performance management Measurement for accountability create & focus momentum for delivery

@helenbevan Avoiding “de facto” purpose What leaders pay attention to matters to staff, and consequently staff pay attention to that too Shared purpose can easily be displaced by a “de facto” purpose:  hitting a target  reducing costs  reducing length of stay  eliminating waste  completing activities within a timescale  complying with an inspection regime If purpose isn’t explicit and shared, then it is very easy for something else to become a de facto purpose in the minds of the workforce Source: Delivering Public Services That Work: The Vanguard Method in the Public Sector

@helenbevan “If people give to a cause, they expect a relationship, not a transaction” Nilofer Merchant

“To return 20,000 well and healthy days to our community”

The “Quality Journey” Compliance Comparison Culture ▪ To meet all required targets ▪ To be better than others, locally or nationally ▪ To be the best we can possibly be ▪ From outside – Imposed ▪ From outside – Top-down ▪ From inside – Internal, personal ▪ Episodic ▪ Ongoing How we define ‘good’ Source of motivation to deliver Duration

Development of goals is a dialogue, top down, bottom up Engagement of health care professionals, especially doctors Integrate measurement into daily work, use it to learn and guide change at all levels Goals and measures used at all levels throughout the organisation Robust and timely data and IT systems A culture of learning, open enquiry, non blame World Leading Organisations I

Dedicated organisational structure for QI All work-streams are assessed against the 6 domains of quality Quality leaders at Board and operational levels Individual responsible for Q and S Standard Improvement methodology adapted for local conditions World Leading Organisations II

Jennifer Dixon: 6 principles for taking QI to scale in NHS 1. Start bottom-up (microsystems) and unleash front line improvement as natural part of daily work and professionalism 2. Focus also on ‘mesosystem’: - Organisational leadership to understand the need for 1 and actively enable it; - Pathways: take a quality measurement/improvement ‘cut’ on provision across whole systems / organisational silos reflecting patient journeys and improve 3. Build skills systematically for microsystem and mesosystem levels [involves skills for front-line and executive tier and trainers/coaches for each level] 4. Evaluation/Applied Health Research: “Evaluation needs to stop letting QI down” – QI methods aren’t acceptable to traditionalists; need to build cachet around QI research/evaluation and methods it (& do this rigorously) 5. Build networks across whole country: provide guidance, “safety in numbers”, allow experimentation and (vitally) “failure linked to learning” 6. Macrosystem (policy) context must be less hostile (eg payment systems, operating framework, regulatory regime). Summed up in shift from policy focusing on organisations to systems and pathways).

How can we support a piece of improvement work around X and Y…that Builds intrinsic motivation, relationships and commitment to our common purpose Uses and generates improvement capability and capacity at Boards Encourages collaboration Supports integration Helps Scotland take those next steps on our Quality Journey

@AndyLongmate