1. GP Clinical Lead SPSP – PC Associate Adviser NES
Quality Improvement
Neil Houston
GP Clinical Lead SPSP – PC Associate Adviser NES

2. Aims What is QI A method of how to do it Develop your own ideas
Preparing for the real world

3. Insanity: doing the same thing over and over again and expecting different results.
Albert Einstein, (attributed)
US (German-born) physicist ( )

4. What is QI?
“the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to: better patient outcomes better system performance better professional development”

5. Healthcare will not realise its full potential unless change making becomes an intrinsic part of everyone’s job, every day, in all parts of the system. Doing the work and working on the work

7. The Model for Improvement
‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’
Dr Donald M. Berwick
Former Administrator of the Centres for Medicare & Medicaid Services
Professor of Paediatrics and Health Care Policy
at the Harvard Medical School
MFI is made up of 2 parts – the thinking part and the doing part
The 3 questions – the thinking part prepares you for the test by asking the ‘so what’ question
They need to be thought through, answered and written down by the improver to ensure that they, and therefore their colleagues, are clear on the benefits to them and their work.
That message often gets lost in the many things we are expected and asked to do and is one of the reasons why so many interventions are not implemented reliably.
If we are not clear on the benefits of something we are much less likely to do it.
The Plan Do Study Act cycle is a simple tool that’s used to test out ideas that will improve your systems and processes while learning what works and doesn’t work.
It’s a structured approach for making small incremental changes to systems that allow you to test on a small scale, learn from successes and failure and redesign as you go
It builds learning and buy in incrementally as tests ramp up and allows clinicians knowledge about their own system is built in to the process

8. 2 main parts to the model – thinking bit and the doing bit:
3 Key questions:
What are we trying to achieve?
Know exactly what you are trying to do
Have clear aims and objectives
How will we know that change is an improvement?
Measuring processes and outcomes
What changes can we make that will result in an improvement?
What do we want to test? What can we learn as we go along?
PDSA
A simple tool – used to test out ideas that will improve systems and processes
A structured approach for making small incremental changes to systems
A full cycle for planning, implementing, testing and identifying further changes
Start small

9. Question 1: What are we trying to accomplish?
Developing the team’s
Aim Statement
Jill Do some more work on the thinking part.... First question – the aim!

10. Aim Statements
Specific
Measurable
Achieveable
Realistic
Timely
Jill

11. Aim Statements You Make the Call!
Andrea

12. 13:45
Ask the delegates to consider these aim statements as a group. Are they Good, bad or Ugly! Get them to spend some time at there tables thinking about these and then should the answers out.
This is bad – it is not ‘how much, by when?’ and it is not site specific i.e. who is we; ICU, Ward 10, A & E?
This is good as it ticks all the boxes for an aim statement, how much, by when and who/where
Urrggh! Ugly! The first sentence is not necessary, the reason for doing it is shifted to ‘mgt has told us’, so it will not have ownership. Use of jargon
This is what I would call a politicians promise, it doesn’t really mean anything. Lauderable aim but not focused or specific so this is bad
This is bad, too wordy, unnecessary information at the start which is better for a team briefing than a statement. Two separate targets and we do not know who ‘our’ is.
This is bad, too wordy, not sure timescale of recent data – two goals and two dates just stick to one goal with one date.

13. “I want to be seen at or near to my appointment time”

14. Aims
95% of patients attending the Opthalmology outpatient department at Forth Valley Royal Hospital will be seen by a clinician within 15 minutes of their appointment time by October 2016

15. Developing an Aim Statement
Team name:
Aim statement
You should review your Aim Statement frequently to make sure it is consistent and that everyone involved with the initiative has a common understanding of what is to achieved.
How will this be measured ?
14:15
Have copies of this on the table for delegates
Measurable (How good?)
Time specific (By when?)
Define participants and customers
Get group feedback following this exercise.
By when?

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

18. 6/23/2018
Change vs Improvement
Of all changes I’ve observed, only about 5% were improvements, the rest, at best, were illusions of progress
W. Edwards Deming
MCPP Healthcare Consulting

19. The answer to this question will guide our entire measurement journey
Why are we measuring?
Research
Improvement
Judgement
The answer to this question will guide our entire measurement journey

20. Measurement for judgement
% waiting over 4 hours in A&E
England by week 2003/04
target
The week Trusts were measured for performance ratings

21. So why measure? To enable us to ‘see’ how we are doing
To enable us to ‘see’ the variation that lives in our daily processes
To tell us whether we are getting closer to our aims?
What are we doing well? Why
What are we not doing so well? why?

22. Three Types of Measures
Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result? Warfarin Control – Reduction in number of strokes Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned? Warfarin – are patients in therapeutic range and appear for bloods tests Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome) Warfarin – number of blood tests taken 2

23. What could you measure? ”
Patients will be seen within 15 minutes of their appointment time
Data for average time after appointment time that patients are called into the clinicians room
How IT
Observation
Questionnaire
What could you measure

24. How often should you measure?

25. We have 2 quarterly data points – is this an improvement?
Higher is better

26. Are we assuming something like this?
Measurement for Improvement

27. But it could be like this ...
Measurement for Improvement

28. Or this ...

29. Or this!

30. PLOT Data over time
Explain why data over time on annotated run charts is useful to staff:
See trend in data
Annotations can help explain the data, ie a deliberate change was introduced/tested, or an event occurred
Data needs to be presented in a way that is understood and is meaningful
ASK – Who collects the data? Where is the data stored? Where does it go?

31. Run chart
A run chart is the simplest of charts. It is a single line plotting some value over time. A run chart can help you spot upward and downward trends and it can show you a general picture of a process.

34. How big a sample? Little and often What would your measurement plan look like ?

35. THEN Shakespeare aim discussion:
Systems – processes & outcomes
Using small tests of change – incremental improvements towards the aim – can we define them & plan them?
Benefits of testing – reduces resistance, reduces risk, increases belief that the change will work.
Did the changes lead to improvement?
What learning came from failed tests?

36. What changes are to be made? Next cycle? Aim & plan the cycle
(who, what, when & how)
14.25
Compare/analyse data, Summarise learning
Carry out the plan
Document problems

37. Anyone for tennis?

38. Instructions At your tables 6 - 9 people Assign a time keeper
Assign a number to each of the other people at your table

39. Break out Exercise
Your current process involves tossing the tennis ball (provided) from person to person, following the sequence provided on the next slide
Practice your process one time
Time keeper please:
Time how long the team takes to complete the process (in seconds)
The number of times they drop the tennis ball 39

40. Exercise Sequence 9 people 8 people 7 people 6 people 5 people 1 2 3 54 8
7 people 1 5 3 4 7 8 2 6
6 people 1 2 3 4 6 7 5
5 people 1 2 3 4 5 6 1 2 3 4 5 40

41. Time? Drops? How low can you get?

42. Break out Exercise
Team Aim: We aim to reduce the time taken for every person to touch the ball in sequence.
We also aim to reduce our ball drops
Rules:
The initial sequence as provided must be adhered to
You may only test one change idea at a time
Record the time and ball drops after each change 42

43. Exercise Sequence 6 people 9 people 8 people 1 2 3 5 7 9 6 4 843

44. How did you get on ? Fastest Time ? Breakthrough Changes?

45. What changes are to be made? Next cycle? Aim & plan the cycle
(who, what, when & how)
14.25
Compare/analyse data, Summarise learning
Carry out the plan
Document problems

46. Building Knowledge with PDSA Tests
Breakthrough Results A P S D
Evidence and data D S P A
Wide-scale tests of Change A P S D
Tests under new conditions (Quantitative data) A P S D
Follow-up Tests
Hunches, Theories, Best Practices
Very Small Scale Test (Qualitative/Quantatiative Data)
Improvement Guide, Chapter 7, p. 146 46

47. A typical approach
This slide shows how previous attempts at change and improvement have been designed
Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; Available: p26

48. An Applied Science Approach
This slide shows how improvement can be achieved using small tests of change
Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; Available: p26

49. You can only learn as quickly as you test.

50. The Value of “Failed” Tests
“I did not fail one thousand times; I found one thousand ways how not to make a light bulb.”
Thomas Edison

51. Start Small 1 patient 1 day 1 admission 1 clinician
“If you think we can test the change in a month, what can you test a day from now?”
Small scale, quick tests
teams are most effective when they move quickly to testing changes (& maintain momentum)
best to first test innovative changes on a small scale
okay to test multiple changes at once
test under a variety of conditions
importance of linking tests of change
don’t try to get buy-in or consensus for tests (but will be necessary for implementation)

52. PDSA - Improve Compliance of Patients Attending Monthly Blood Monitoring
Ensure patients prescribed Methotrexate or Azathoprine attend a monthly review for blood monitoring
Patients complying by attending blood monitoring will increase
Using a variety of engagement methods
Patients engaging
5 Stop repeat prescription until they attend
4 Restrict the amount of repeat prescription available to them to encourage attendance
3 Put a note on patients repeat prescription
2 Send information stating reasons for why it is important to attend
1 Invite patients who have failed to comply by telephone 52

53. Will
Ideas
Execution

54. Adverse events in primary care cause: 1 in 20 deaths in hospital
PATIENT SAFETY IN PRIMARY CARE - WHY BOTHER?
Adverse events in primary care cause:
1 in 20 deaths in hospital
6.7% of admissions linked to adverse reaction to medication
4% of hospital bed capacity
1-2% of consultations in Primary care have potential for harm
To Err is Human 1999
Howard et al Br J pharmacology 2006
Zhang et al BMJ 2009
Howard et al qshc 2003
Adverse vents in Primary care do cause significant harm and much of it is preventable

56. Process mapping Just to explain what is meant by process map.
Haven’t a chance of reading it but it is a flow chart showing the process from the patient attending practice for a blood test to check INR.
Seen like this it is interesting to see how many tasks (12) must be carried out by practice and lab compared with the 6 communications with the patient.
The reason for showing this is that the patients identified situations where the actual process did not meet the mapped process.
Action was taken to remedy these problems. 56

57. Ideas

58. Challenges to Execution

62. How are you going to go back and engage with your team?