North Tees and Hartlepool NHS Foundation Trust Clinical Leadership Development Programme Leadership and Improvement

Jean Penny BPR Leicester Royal Infirmary 1994 - 1999 All working life in NHS Diagnostic Radiographer and teacher Improvement roles since 1994 BPR Leicester Royal Infirmary 1994 - 1999 National Patients ‘Access Team 1999 - 2002 NHS Modernisation Agency 2002 – 2005 NHS Institute for Innovation and Improvement 2005 -2008 Awarded OBE for services to NHS 2003 Visiting professor University of Derby 2008 Jean.penny@btinternet.com Improvement: 17 years and still learning

Agenda Understanding the skill of improvement Linking strategic goals and frontline improvements

You have all made improvements What tools and techniques, knowledge and skills are needed to make good sustainable improvements? If you are familiar with ‘Lean’ ‘LIPS’ ‘Productive Ward’’, what are the underpinning tools and techniques

Theory of constraints Any improvement is a change Eliyahu Goldratt not every change is an improvement but we cannot improve something unless we change it Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

Theory of constraints Any improvement is a change any change is a perceived threat to security there will always be someone who will look at the suggested change as a threat Eliyahu Goldratt

Theory of constraints Any improvement is a change any change is a perceived threat to security any threat to security gives rise to emotional resistance you can rarely overcome emotional resistance with logic alone Eliyahu Goldratt

“Anyone who thinks you can overcome emotional resistance with logic was probably never married”

Theory of constraints Any improvement is a change any change is a perceived threat to security any threat to security gives rise to emotional resistance emotional resistance can only be overcome by a stronger emotion Eliyahu Goldratt

Share the problem not the solution What to change? Pin point the core problems What to change to? Construct (simple) practical solutions How to cause the change? Induce the appropriate people to invent such solutions they must own the problem Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

Leadership framework for improvement 1. Set Direction: Mission, Vision and Strategy Make the future attractive Make the status quo uncomfortable 3. Build Will Plan for improvement Set aims/allocate resources Measure system performance Provide encouragement Make financial linkages Learn subject matter 4. Generate Ideas Understand organisation as a system Read and scan widely, learning from other industries and disciplines Benchmark to find ideas Listen to patients Invest in research and development Manage knowledge 5. Execute Change Use Model for Improvement for design and redesign Review and guide key initiatives Spread ideas Communicate results Sustain improved levels of performance 2. Establish the Foundation Reframe operating values Build improvement capability Prepare personally Choose and align the senior team Build relationships Develop future leaders Source: Robert Lloyd Executive Director Performance Improvement Institute for Healthcare Improvement January 16, 2007

Knowledge about Variation Knowledge of Psychology Deming Knowledge of Systems Theory of knowledge Knowledge about Variation Knowledge of Psychology W Edwards Deming (1994) The New Economics

Discipline of improvement 4 equally important parts of improvement People User and public involvement Diagnostic tools e.g. Process and systems thinking Process What Change management Project and programme management How Discipline of improvement in health and social care (Penny 2003)

‘Every single person is enabled, encouraged and capable to work with others to improve their part of the service.’ People User and public involvement Diagnostic tools e.g. Process and systems thinking Process What Change management Project and programme management How Discipline of improvement in health and social care (Penny 2003)

Linking strategic goals and frontline improvement

Understand the complexity of your project Macro Meso Micro ©Profound Knowledge Products, Inc. 2008 All Rights Reserved

Aim The ‘big’ dots Drivers Interventions The ‘small’ frontline dots Ask yourself What is the big (possibly strategic) problem you are addressing? What are you trying to achieve? (aim) How will you know a change is an improvement ? (outcome measures) Ask yourself What are the problems that cause the bigger problem? What are you trying to achieve? (aim for each driver) How will you know a change is an improvement ? (outcome measures for each driver ) Drivers Which in turn contribute directly to the ‘bigger’ aim Ask yourself What changes can you make that will result in the improvement you seek? What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing? How will you know a change is an improvement? (process measures for each intervention) Intervention 1 Intervention 2 Intervention 3 Interventions The ‘small’ frontline dots Contribute directly to the drivers

? The strategic aim (and big problem) Primary Drivers: Contribute directly to the strategic aim Secondary Drivers: Contribute directly to primary drivers The interventions / change ideas that contribute directly to secondary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 ? Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3

Reduce surgical site infections Primary Drivers Secondary Drivers Appropriate use of prophylactic antibodies Maintain normothermia Reduce surgical site infections Maintain glycaemic control in known diabetes Reducing harm in perioperative care Use recommended hair removal methods Use of the WHO Surgical safety checklist Improve team work and communications Ref. Patients Safety First

‘High level Aims and objectives’ North Tees and Hartlepool NHS Foundation Trust Corporate strategy 2010 – 2015 Patient safety Patient satisfaction Staff satisfaction Provider of choice Quality of services Governance and mandatory services Financial stability New facilitates Care delivered closer to home ‘High level Aims and objectives’ Pages 26 - 29

? The strategic aim (and big problem) Primary Drivers: Contribute directly to the strategic aim Secondary Drivers: Contribute directly to primary drivers The interventions / change ideas that contribute directly to secondary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 ? Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3

Measurement: Big dots and little dots The Model for Improvement breaks things down into small steps and works of the ‘little dots’ – at the frontline These small steps should be part of the answer to the question of how to move the big dots Align all improvement projects to strategy

Act Plan Study Do What are we trying to accomplish? Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives The more specific the aim, the more likely the improvement Repeated clarification - without it aims drift Meet needs of external customers Model for Improvement What are we trying to accomplish? How will we know that a Measuring processes and outcomes change is an improvement? What change can we make that will result in improvement? What have others done? What hunches do we have? What can we learn as we go along? Act Plan Study Do Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nd ed, Jossey Bass Publishers, San Francisco 23

First define the problem Root Cause Analysis (5 Whys) Process Mapping Ishikawa (Fishbone) Brainstorming Pareto Analysis etc And User and staff stories and anecdotes 24

What are the problems for users, carers and staff and what are the causes of the problem? Ishikawa (Fishbone) Diagrams People Place PPPP Procedures Policies 25

Example Cause & Effect Diagram © 2004 Institute for Healthcare Improvement 26

Use Pareto Principle to identify cause(s) of problem to work on first ‘The 80-20 Rule’ ‘The Law of the Vital Few’ For many phenomena, 80% of the consequences stem from 20% of the causes Observation that 80% of income went to 20% of the population Vilfredo Pareto, 1906 27

Act Plan Study Do What are we trying to accomplish? Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Model for Improvement What are we trying to accomplish? How will we know that a Measuring process, outcomes and balancing change is an improvement? What change can we make that will result in improvement? What have others done? What hunches do we have? What can we learn as we go along? Act Plan Study Do Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco 28

The Three Faces of Performance Measurement Aspect Improvement Accountability Research Aim Improvement of care Comparison, choice, reassurance, spur for change New knowledge Methods: Test Observability Tests are observable No test; merely evaluate current performance Test blinded or controlled tests Bias Accept consistent bias Measure and adjust to reduce bias Design to eliminate bias Sample Size “Just enough” data, small sequential samples Obtain 100% of available, relevant data “Just in case” data Flexibility of Hypothesis Hypothesis flexible, changes as learning takes place No hypothesis Fixed hypothesis Testing Strategy Sequential tests No tests One large test Determining if a Change is an Run charts or control charts No change focus Hypothesis, statistical tests (t-test, F-test, chi square), p-vlaues Confidentiality of the Data Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected Robert Lloyd Executive Director IHI adapted from Solberg L, Mosser G, Mcdonald S (1997) Three faces of performance measurement: Improvement, accountability and research Journal of Quality Improvement Vol. 3 No 3

Charts vs. Tables 30

What does this tell us?

What does this tell us?

Given two different numbers, one will always be bigger than the other! Something very important! Last month This What action is appropriate?

What does this data tell us? 21.6 23.9 23.3 22.6 28.8 22.7 23.8 22.8 28.7 22.9 24.2 23.3 28.6 22.8 23.9 23.2 23.7 28.5 23.2 23.5 23.1 27.7 34

What does this data tell us? Mean = 24.4 5 10 15 20 25 30 1 2 3 4 6 7 8 9 11 12 13 14 16 17 18 19 21 22 Weekly production volume July Aug Oct Sept Week 35

Run charts Seven one side DO Seven down (or up) 90 80 70 60 Seven down (or up) Seconds to answer phone 50 40 DO 30 20 10 1 4 7 10 13 16 19 Day Look for a run of seven points all above or all below the centre line or all increasing or all decreasing 36

How often you measure can also have an effect on how you look at the results Average length of pre-ward stay Stroke Ward from 01/2007 to 07/2007 0.5 1 1.5 2 2.5 3 3.5 4 5 6 7 Months Average length of pre-ward stay Stroke Ward from 01/2007 to 07/2007 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 Weeks Patient length of pre-ward stay Stroke Ward from 01/2007 to 07/2007 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Patients Mike Davidge NHS Institute for Innovation and Improvement

North Tees and Hartlepool NHS Foundation Trust Corporate strategy 2010 – 2015 Strategic measures Patient safety Patient satisfaction Staff satisfaction Provider of choice Quality of services Etc etc

Aim The ‘big’ dots Drivers Interventions The ‘small’ frontline dots Ask yourself What is the big (possibly strategic) problem you are addressing? What are you trying to achieve? (aim) How will you know a change is an improvement ? (outcome measures) Ask yourself What are the problems that cause the bigger problem? What are you trying to achieve? (aim for each driver) How will you know a change is an improvement ? (outcome measures for each driver ) Drivers Which in turn contribute directly to the ‘bigger’ aim Ask yourself What changes can you make that will result in the improvement you seek? What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing? How will you know a change is an improvement? (process measures for each intervention) Intervention 1 Intervention 2 Intervention 3 Interventions The ‘small’ frontline dots Contribute directly to the drivers

Act Plan Study Do What are we trying to accomplish? Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Model for Improvement What are we trying to accomplish? How will we know that a Measuring processes and outcomes change is an improvement? What change can we make that will result in improvement? Change ideas: What have others done? What hunches do we have? What can we learn as we go along? Act Plan Study Do Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2nd ed, Jossey Bass Publishers, San Francisco 40

Change principle Change principle Transferring solutions is rarely effective, Transfer change principles… Change principle Change principle Solution / change in organisation A Solution / change in organisation B

PDSA cycle for learning and improvement Act Plan objective questions and predictions (why) plan to carry out the cycle (who, what, where, when) what changes are to be made? next cycle? Study Do complete the analysis of the data compare data to predictions summarise what was learned carry out the plan document problems and unexpected observations begin analysis of the data

Speaking in PDSA Language We planned to….. ( state the basic plan) In order to ….. (tie it back to the Aim) What we did was….. (brief description of actions) Looking at what happened, what we learned from this was….. ( lessons learned) What we plan to do next is …. (state next plan) P D S A © Paul Plsek

Repeated PDSA cycles work towards the AIM What am I trying to achieve? How will I know a change is an improvement? What changes can I make that will result in the improvement PDSA PDSA PDSA PDSA Data Driven Change PDSA Hunches Theories Ideas Change in Team Culture Need to start small!!

Leading improvement Trust: Caring & Competency HIGH Affection Trust Distrust Respect Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill Extent to which I believe you care about me LOW HIGH Extent to which I believe you are competent and capable

What are the three key messages you have got from this session? Think quietly by your self for a few minutes

Act Plan Study Do 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? Model for Improvement Act Plan Study Do