1. Quality Improvement Projects - the basics Dr Sue Cullis FRCGP Associate Postgraduate Dean HEEM. Dr Graham Toddd MRCGP Primary Care Educational Lead HEEM

2. Acknowledgements Dr Martyn Diaper NHSIQ Alison Tongue NHSIQ Orlando Hampton HEEM Prof. Jean Penny O.B.E University of Derby.

3. www.em.hee.nhs.uk Learning Objectives To understand the role of PDSA and run charts in a Quality Improvement Project. To understand some of the other tools used in quality improvement To learn where to find more information & resources.

4. Do GPs need to do this? Trainees should ‘take part in systems of quality assurance and quality improvement in their clinical work and training.’ Gold Guide 2014 ‘A progressive curriculum in quality improvement activity should underpin all training stages of a doctor, building capability and leadership, and a foundation for on-going lifelong learning and implementation.’ Academy of Royal Colleges, March 2016 ‘For the purposes of revalidation, you will have to demonstrate that you regularly participate in activities that review and evaluate the quality of your work. Quality improvement activities should be robust, systematic and relevant to your work. They should include an element of evaluation and action, and where possible, demonstrate an outcome or change.’ revalidation.walesdeanery.org

5. So yes, we do need to do this! – but what is quality care? Safe Timely Effective Efficient Equitable Patient - Centered

6. So How Can We Improve Quality?

7. What are we trying to accomplish? How will we know that a change is an improvement? What small change can we make to reach our aim? The Model for Improvement Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

8. 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 ActPlan StudyDo Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Measuring processes and outcomes Change ideas: What have others done? What hunches do we have? What can we learn as we go along? Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organisational performance 2 nd ed, Jossey Bass Publishers, San Francisco

9. Repeated PDSA cycles work towards the AIM PDSA Data Driven Change Hunches Theories Ideas 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 Need to start small!!

10. Change through small steps Change... with a clear purpose you can learn from (without fear of failure) which is less exhausting with fewer unintended consequences which builds engagement and optimism

11. Benefits of this approach easier to start produces better solutions more quickly engages people better reduces waste easier to continue

12. What are we trying to accomplish? PDSA Cycle – Question 1 So how can we find out what needs improving?...  By looking at data we already have – e.g. complaints, comments, questionaires, audits, significant events etc  By using other QI tools – e.g. 360 patient safety appraisal (including walkrounds & trigger tools), niggle lists, process mapping

13. How will we know that a change is an improvement? PDSA Cycle – Question 2 By measuring carefully over time… Using run charts where possible Or multiple data collection where not possible Being aware of the danger of averages Being aware that change may produce harm or have no effect Let’s look at measurement for improvement more carefully…

14. The traditions of measurement eg A-B comparison, average, huge dataset Research eg one-to-many benchmarking comparison, average, large dataset Judgement eg continual analysis of single changing process over time Improvement

15. What mindsets are at play here? Mindsets Research Improvement Judgement

16. ResearchJudgementImprovement Goal New knowledge (not its applicability) Comparison Reward / punishment Spur for change Process understanding Evaluating a change Hypothesis FixedNoneMultiple and flexible Measures ManyVery fewFew Time period Long, pastLong/medium, pastShort, current Sample Large Small Confounders Measure or controlDescribe and try to measure Consider but rarely measured Risks in improvement settings Ignores time based variation Over-engineers data collection Ignores time based variation Over-reaction to natural variation Incorrectly perceived as ‘inferior statistics’ Measurement mindsets Based on L Solberg, G Mosser and S McDonald (1997) The Three Faces of Performance Measurement: Improvement, Accountability and Research, Journal on Quality Improvement, 23 (3): 135 - 147.

17. What to measure? StructureProcessOutcome Avedis Donabedian ‘Outcomes remain the ultimate validators of the effectiveness and quality of medical care’ but they ‘must be used with discrimination’ The environment in which care occurs What care is delivered, and how The impact

18. OUTPUTS HUMAN FACTORS HUMAN FACTORS INTERNAL PROCESSES & PROCECEDURES INPUTS EXTERNAL FACTORS Process Measure(s) What to measure? Is it being done? Is it working? Unintended consequences? system fit for use?

19. Period 1 Period 2 Poor performance Good performance Period 1 Period 2 Change made Period 1 Period 2 Poor performance Good performance Improvement! p<0.05 With summary data we make judgements about improvements We may use summative statistics to justify it (e.g. confidence intervals) But processes can change over time and tell a different story! Imagine this is mortality data Approaches to monitoring performance Target A change was introduced between the two periods. Was it a success?

20. 20 Measurement for learning

21. Run charts: measurement for learning 0 10 20 30 40 50 60 70 80 90 Day 1 4710131619 Seconds to answer phone Seven one side Seven down (or up) DO Look for a run of seven points all above or all below the centre line or all increasing or all decreasing Just like a TPR chart

22. Average length of pre-ward stay Stroke Ward from 01/2007 to 07/2007 0 0.5 1 1.5 2 2.5 3 3.5 1234567 Months Mike Davidge NHS Institute for Innovation and Improvement 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

23. Understanding variation “Common Cause” inherent in the design of the process variation is predictable and the process is stable affects process most of the time many factors, some “unknowable” “noise in the system” “Special Cause” not part of the process unpredictable variation intermittently apparent “assignable” causes can usually be identified

24. What small change can we make? PDSA Cycle - Question 3 We may know what we want to improve (question 1) And know how we are going to measure over time (question 2) But what small thing do we change? Tools to find Change Projects (amongst others)  Process Maps  Driver Diagrams

25. eg How do at-risk infants get Vitamin D? Deliberate reliable design – ??? An example of a process map

26. Process maps can reveal gaps

27. Pedometer Gym work out 3 days Squash weekends No pub weekdays Take packed lunch Low fat meals Buy only 1 sandwich Water bottle for work bag Fruit for dessert Put away large wine glasses Put cycling days in diary Cycling kit out night before Get rid of Oyster card Take stairs 2 stone weight loss in 6/12 Driver Diagrams Help Generate Change Ideas

28. Pedometer Gym work out 3 days Squash weekends No pub weekdays Take packed lunch Low fat meals Buy only 1 sandwich Water bottle for work bag Fruit for dessert Put away large wine glasses Put cycling days in diary Cycling kit out night before Get rid of Oyster card Take stairs Be more active during the day Do sport Drink less alcohol Substitute lower calorie foods Eat less Marshall the mass of ideas 2 stone weight loss in 6/12

29. Driver Diagrams Weight loss example Pedometer Gym work out 3 days Squash weekends No pub weekdays Take packed lunch Low fat meals Buy only 1 sandwich Water bottle for work bag Fruit for dessert Put away the large glasses Put cycling days in diary Cycling kit out night before Get rid of Oyster card Be more active during the day Do sport Drink less alcohol Substitute lower calorie foods Eat less Reduce calories in Reduce calories in Increase calories out Increase calories out Take stairs 2 stone weight loss in 6/12

31. What are we trying to accomplish? How will we know that a change is an improvement? What small change can we make to reach our aim? PDSA Cycle Recap Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994 But Why Should Changes Be Small?

32. Think Small Because…. 70% of change fails

33. So Prioritise - Focus your effort where it matters Think small because of The Pareto Principle

34. The Pareto Principle We don’t have time to improve everything A small number of issues account for the majority of the challenge 20% of causes account for 80% of the problem We should focus on the ‘critical few’, not the ‘trivial many’

35. What does it look like? Interruptions in surgeries Tally by GPs of the causes of interruptions while seeing patients. CategoryCount% of TotalCumulative % Cancellation msg58838.9 Admin info31220.659.5 Chaperone19813.172.6 Sign script - urgent785.277.8 Other724.882.6 Sign script - contraception724.887.4 Clinical query - GP664.491.8 Equipment search60495.8 Clinical query - NP241.697.4 Clinical query - learner181.298.6 Sign script - minor illness nurse181.299.8 Panic button60.4100.2 TOTALS1512100

36. The Pareto Principle - an example Three categories of interruption (17%) account for 73% of the problem

37. Learning Objectives - Recap 1.To understand the role of PDSA and run charts in a Quality Improvement Project. 2.To have heard about some of the other tools used in quality improvement 3.To learn where to find more information & resources….

38. www.em.hee.nhs.uk Links to Other Useful Resources. http://www.ihi.org http://www.vle.eastmidlandsdeanery.nhs.uk/ Search for “QI Resources” www.changemodel.nhs.uk www.nhsiq.nhs.uk www.qihub.scot.nhs.uk/home.aspx

39. www.em.hee.nhs.uk BMJ Quality This is an online guide to doing a quality improvement project with links to BMJ Learning modules on relevant topics. It guides you through the process from start to finish and you can publish your project in their online Quality Journal. Licenses are available on a first come first served basis by discussing with your PDs.

40. www.em.hee.nhs.uk BMJ Quality www.quality.bmj.com

41. www.em.hee.nhs.uk Our Contact Details Dr Sue Cullis. APD scullis@nhs.netscullis@nhs.net Dr Graham Todd todds@doctors.org.uktodds@doctors.org.uk

42. www.em.hee.nhs.uk East Midlands QI Forum Planned for June 2015. Multi-professional multidisciplinary event. An opportunity to showcase the best QI projects done by trainees. Exciting QI keynote speakers. 42

43. www.em.hee.nhs.uk “ The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.” Don Berwick. A promise to learn - a commitment to act. August 2013. A Final Thought from Don Berwick