1. Quality improvement in action:
A core competence of medical education in the 21st century
Dr Emma Vaux
@VauxEmma

2. What is Quality Improvement?
@NHS_HealthEdEng

3. Quality is:
Patient care that focuses on safety, effectiveness and patient experience
[NHS Constitution]
Quality improvement is:
Using understanding of our complex healthcare environment,
applying a systematic approach
designing, testing, and implementing changes using real-time measurement for improvement,
to make a difference to patients by improving safety, effectiveness & experience of care.
QI education
Knowledge in improvement science, systems and measurement
Skills in managing complexity, leading change, learning and reflection, and ensuring sustainability
Training in human factors that impacts those capabilities
What is the right thing = research
Clinical audit – are we doing the right thing and how are we doing
QI – how can we make the right thing happen every time – which is also part of the audit cycle

4. Systems thinking
Tame – complicated but less uncertainty; there is an answer……….rota, fix a broken leg, elective surgery op list, hospital design – there is always an answer
Wicked (or big hairy problems) more complex – uncertainty – not right or wrong answer – best solution - any solution likely impact elsewhere in the system eg patient fall – health and social care; best care for obese type II diabetic, emergency admissions,

5. Reliability and the Number of Steps
1 step at 95% reliability says that it succeeds 95/100 (or fails 5/100 times)
Probability of Success
25 steps at 95% reliability for each step says it succeeds 28/100 (or fails 72/100) (.95 x .95 x .95 x .95 for 25 times)
The probability of success is highly correlated with the number of steps in a process!
10-2—what we are trying to achieve in healthcare—but wait, what does it really mean?
1 step at 95% reliability says that it succeeds 95/100 (or fails 5/100 times) when step is done;
25 steps at 95% reliability for each step says it succeeds 28/100 (or fails 72/100) (.95 x .95 x .95 x .95 for 25 times)
40 steps at 95% reliability for each step says it succeeds 12/100 (or fails 88/100)
100 steps at 95% reliability for each step says it succeeds .6/100 or 6/1000 times (or fails 99.4/100 or 994/1000)
Many of our process are at the complexity level of 100 steps—we need higher reliability!
40 steps at 95% reliability (12/100 successes or fails 88/100)
100 steps, (99.4 out of 100 are failures)

6. Complexity and Reliability
Aim: “95% compliance with Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision”
(4 step process) 1 2
Probability of on-time successful completion at each step
Steps
90.00%
99.00%
99.90%
99.99%
99.999% 1 2
81.00%
98.01%
99.80%
99.98%
99.998% 4
65.61%
96.06%
99.60%
99.96%
99.996% 8
43.05%
92.27%
99.20%
99.92%
99.992% 16
18.53%
85.15%
98.41%
99.84%
99.984% 32
3.43%
72.50%
96.85%
99.68%
99.968% 64
0.12%
52.56%
93.80%
99.36%
99.936%
128
0.00%
27.63%
87.98%
98.73%
99.872% 3
How does the complexity of your process affect reliability? 4
If the reliability of each step is 90% then the overall reliability for the 4 steps together is only 65.61% (.90^4=.6561) 2

7. DAVE

8. “All improvement requires change, but not all change leads to improvement”

9. “In God we trust. All others bring data.”
W. E. Deming

10. Top tip 1
A methodology

12. Top tip 2
Measurement

13. 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
Test observable
No test, evaluate current performance
Test blinded or controlled
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
improvement
Run charts or Shewhart control charts
No change focus
Hypothesis, statistical tests (t-test, F-test, chi square),
p-values
Confidentiality of
the data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
So to recap what is improvement data doing compared with data for research
We are making what we know to be best practice happen in real life working environments, rather than highly controlled situations
What is improvement data doing compared with accountability data-
it is motivating staff with small tests and
ongoing vigilance to get better,
there is a hypothesis lets try it out and see,
The hypothesis changes

20. before
after

21. Top tip 3
QI, audit and research are synergistic

22. Translational Research
Quality Improvement is a T3 enterprise
Westfall, J. M., J. Mold, et al. (2007). "Practice-Based Research--"Blue Highways" on the NIH Roadmap.“ JAMA 297(4):
Khoury, M. J., M. Gwinn, et al. (2007). "The continuum of translation research in genomic medicine: how can we accelerate the appropriate integration of human genome discoveries into health care and disease prevention?" Genet Med 9(10):
Making Every Moment Count
Understanding Measurement for Quality Improvement • Sept 10&

23. Opportunity:
Make it real-time & dynamic

24. Repeated Use of the PDSA Cycle for audit
Changes That Result in Improvement A P S D
DATA
Spread D S P A
Implementation of Change A P S D
Wide-Scale Tests of Change A P S D
Follow-up Tests
Hunches Theories Ideas
Standards
Very Small Scale Test
DATA
so having tested a change once and it worked ……what then ?
do it again on a different patient , or bay instead of one patient
get two nurses to try it instead of one
Ask a colleague working on another ward to try the same test with a different case mix 24

25. Top tip 4
Stakeholder engagement

30. Top tip 5
Sustainability

32. Sustainability Patient & staff engagement Fits with goals & structures
Infrastructure
Credibility of evidence
Adaptability:
Monitoring progress:

33. 4 principles sustainable clinical practice Prevention
Sustainable value in healthcare
4 principles sustainable clinical practice
Prevention
Patient empowerment & self-care
Lean systems
Low carbon alternatives

34. Top tip 6
Visibility

36. Prevention of hospital acquired pneumonia

37. Top tip 7
Junior doctor & MDT involvement

38. "The aggregation of marginal gains."
‘You hear about projects and they sound really huge but this has opened my eyes to how you can do little things and make small changes that make a big difference’

39. Top tip 8
Role modelling

40. Look beyond the tick box……

41. Top tip 9
Patient involvement

42. Patricia Peattie, Chair Academy Patient Lay Group
“We should start with the patient. It is important that quality improvement starts with what is important and not with what is easy to address”
Patricia Peattie, Chair Academy Patient Lay Group
@MyLifeScribble
@VauxEmma

43. Top tip 10
Time to do it!

45. Value your Time! Design & Planning Little and often measurement
Prospective
Real-time
Encouraged to work as team
Measurement as part of workflow

46. Influencing
Systems thinking
learning
creativity
Resilience

47. Getting started….
Collecting plans at end and will be returned….