1. An Introduction to Quality Improvement
Dr Andrew Longmate, National Clinical Lead for Safety

4. Between the health care we have and the care we could have lies not just a gap, but a chasm.
Best-known science is not reliably applied.
Inefficiencies waste resources.
Patients are being harmed
It takes 17 years for 14% of evidence based science to be reliably applied

5. Having the best professionals in the world is no longer enough

6. Subject Matter Knowledge
Two Types of Knowledge
Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge.
Improvement
Subject Matter Knowledge
Profound Knowledge
Profound Knowledge (W.E. Deming): The interaction of the theories of systems, variation, knowledge, and psychology.
From L. Provost

7. Quality Improvement
The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to
better patient outcome, better system performance, and better professional development.
For me, quality improvement means…or put in a graphical form…
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

8. A clear and stretch goal A method Predictive, iterative testing
Our change theory
A clear and stretch goal
A method
Predictive, iterative testing

9. Aim
Measures
Changes
Execution
The Improvement Guide, API 9 9

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

12. Aim
The Improvement Guide, API 12 12

13. “Aims create systems”
Deming

14. What’s Our Constancy of Purpose ?
Our national context.
Our national aim – driven by the Scottish Patient Safety Programme and led by the Scottish Government

15. The Healthcare Quality Strategy for Scotland
Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.
Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.

16. Aim
How much ?
By When ?
(some is not a number, soon is not a time, hope is not a plan)
Aims infuse meaning and hope in our lives, they create a target to achieve and inspire and motivate us to achieve it.
SMART
Specific
Measurable
Achievable
Realistic (BUT A STRETCH- not possible to achieve by working the same way we have been working)
Timely
Goals and aims help in taking some of the crucial decisions of our lives. You can actually decide what do you want and chalk out a plan to achieve it. Lack of an organized planning or aim, one may wander aimlessly and time might take decisions for us. Aims infuse meaning and hopes in our lives, it creates a target to achieve and inspire and motivates us to get it.

17. Develop your own aim statement
At your table develop an aim statement to
become an expert in Shakespeare
Explicit over arching description
Specific actions or focus
Goals
Measurable (How good?)
Time specific (By when?)
Define participants and customers

18. Measurement
The Improvement Guide, API 18 18

19. All improvement requires change but not all change will result in an improvement
Langley et al, 20009; The Improvement Guide

20. Is the change an improvement?
Improvement is NOT just about measurement However… without measurement you will never be able to answer the question

21. Question 2: How do we know that a change is an improvement?
“When you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind.”
Lord Kelvin, May 3, 1883
Remember that the second question in the Model for Improvement is “How Do We Know That a Change is an Improvement?” The collaborative is about change, not about measurement, but measurement is important to support the improvement work of the team.
Now for your plan and predictions. How will you know that a change is an improvement? Without measuring your change you can never be confident that it is improvement. You can do this in terms of the way in which your results or outcomes might be different . How the service that your patients receive will be better or how your processes may change.
PLAN really important – look at the details. If you don’t know exactly what to next when you have a plan, then it is not right. How do you plan to make the space for that 30 minute walk to work? Prediction is important, especially when get to harder tests. If you predict, you can then identify how to measure/ record/ evaluate.
Have a go at your plan and predictions.
Then Do it, Study it, Act to change for the next test. So getting the walking time meant reorganising the morning routine, but when it came down to it, no-one else but you was ready when they said they would be ready – a failed test. But this was only the first try, so nothing much has been lost, and there is the potential to learn something useful. How can the plan be adjusted for another try? What was it specifically that caused the failure this time?
Data is motivational. It needs to be used, displayed, discussed, acted upon.
“In God we trust. All others bring data.” W. E. Deming

22. Key measurement assumptions
The purpose of measurement in improvement science is for learning not for judgement
Measurement for improvement is different to measurement for research
All measures have limitations

23. Three types of measures
Outcome Measures Directly relates to the overall aim
Voice of the person patient
How is the system performing?
Process Measures The workings of the system.
Balancing Measures Looking at a system from different directions.
e.g. unanticipated consequences
When measuring for improvement we may have measures that are outcome, process or balancing.
Outcome measures are…they are a must have. If our collaborative does not have outcome measures it is difficult to justify the time/expense. How will we convince anyone that we made a difference to the patient/customer??
Process- Early indicators of improvement…logically connected to outcome….it can be easy to overdo the # of process measures, so be careful. Remember changing the process is easier than trying to change the person. When you examine the data, usually compliance with the process is the issue that comes to light.
Balancing: optional but wise to have one or two. Explained on next slide
Usually error, harm, quality issues are usually something to do with the process not being followed, either because it is to complex, makes no sense so people do their own process which introduces variation.

24. Here’s the ladies toilets in Jon Koping
W Edwards Deming

25. Ventilator Associated pneumonia – Forth Valley ICU

26. “What is the variation in one system over time. ” Walter A
“What is the variation in one system over time?” Walter A. Shewhart - early 1920’s, Bell Laboratories
time
UCL
Dynamic View
Static View
Static View
LCL
Static View

27. “Every system is perfectly designed to achieve exactly the results it gets.”
Dr Paul Bataldan
If you always do what you’ve always done, you’ll always get what you’ve always got...

28. 2 quarterly data points is this an improvement?
Higher is better

29. “When you have two data points, it is very likely that one will be different from the other.”
W. Edwards Deming

30. Or are we assuming something like this?

31. But it could be like this ...

32. new rules – concentrate on process
Process measures are collected in a practice or unit -those results can give the team the needed success
If process becomes highly reliable the outcome will follow as long as it is connected to science
Outcome measures will most likely lag behind process measures
Leaders should tend to focus on outcome while individual teams should be held responsible for process reliability

33. GGC Interface Medicines Reconciliation
Alexa Wall, NHS Lanarkshire
Rachel Bruce, NHS Greater Glasgow and Clyde

34. GGC Primary Care DMARDS Bundle Compliance
Alexa Wall, NHS Lanarkshire
Rachel Bruce, NHS Greater Glasgow and Clyde

35. Testing
The Improvement Guide, API 35 35

36. A typical approach
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

37. An Applied Science Approach
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

38. Why Test Changes?
To learn how to adapt the change to conditions in your setting
To increase the belief that the change will result in improvements in your setting
To evaluate the costs and “side-effects” of changes
Overall a fundamental part of reliable implementation which will minimise the resistance when spreading the change throughout the organisation.
Now we’re going to talk about the doing bit....
The more you test it and the more positive changes you make, the better the end result will be.

39. 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

40. “failing towards success”
He and his teams actively celebrate failure – because failure represents the learning…

41. What will happen if we try something different?
The PDSA Cycle
What will happen if we try something different?
What’s next?
Four parts of the cycle:
Plan:
Decide what change you will make, who will do it, and when it will be done. Formulate an hypothesis about what you think will happen when you try the change. What do you expect will happen?
Identify data that you can collect (either quantitative or qualitative) that will allow you to evaluate the result of the test.
Do:
Carry out the change.
Study:
Make sure that you leave time for reflection about your test. Use the data and the experience of those carrying out the test to discuss what happened. Did you get the results you expected? If not, why not? Did anything unexpected happen during the test?
Act:
Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale?
Did it work?
Do It !!!

42. Key Points to Remember PDSA’s cannot be too small
One PDSA will almost always lead to another
You can achieve rapid results
They help you to be systematic & learn from your work
Anyone can use them in any area

43. 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)

44. TO BE CONSIDERED A PDSA CYCLE…
The test was planned (including a plan for collecting data).
The plan was attempted (do the plan). (Make a prediction)
Time was set aside to analyze the data and study the results.
Action was rationally based on what was learned.
Page 39 in the Improvement Guide discusses this cycle. It is hard work to do a complete cycle.
Plan: Most did not have plan for collecting data for improvement - just outcome--Plan has to have data collection in order to advance the science. Did we have a plan?
Do: Did we attempt the plan? We did activity-but not a very complete plan
Study; Time set aside to study the result—we did that. What data--just picked experts and studied them. We have some good outcome data. But we didn’t have good process data in the Peg Game. Great theories when we have anointed the expert, after the fact anyone can sound like they know something.
Action: is it rational just to copy the best performers????
Action was rationally based on what was learned? So maybe we did not make progress in learning. When we made the winner the expert, was that a rational way to proceed? If we actually wanted to run a PDSA cycle, what would we do?
Source: Improvement Guide pp 27 2

45. YOU CAN ONLY LEARN AS QUICKLY AS YOU TEST.

47. Time to see if you can conduct PDSAs!
Hmmmmmmm…
I wonder if these adults can do PDSAs as fast as I can.
Time to see if you can conduct PDSAs!

48. Objective
To run PDSA tests until you end with only one skittle left on the worksheet

49. The Peg Exercise: The Set Up
-If use overhead use coins on overhead because M&M’s melt
-First cycle-Everyone do it- soup in 3 min-be fast!
-Use blank transparency or flipchart to create histogram of results.
Leave room for 3 more histograms on transparency
-Who got best score? Want to get our experts to share
-Hope for someone who got a 1! Get ideas from each 1--write on flip chart. If no one use 2’s. Usually more of them. Use a couple of volunteer s- get ideas. If conflicting methods discussed by volunteers facilitator draws out common principle so no embarrassment. “Great stuff-need to use this!”
--Go back and have everyone try it again using method of expert(s).
Do another histogram: usually get some improvement
-Experts who got 1 first time-how did they do?
-Did new people get 1-how get it?
Get group quiet. Ask question. We have (e.e) 20 tables, 8 people per table, 160 people with two rounds of the peg exercise-how many PDSA’s have we run? Please think quietly. Ask for input-write on flip chart. Are trying to get someone to say ‘None”.
Then show slide 8: What it takes to be a PDSA cycle and continue exercise
Copyright 2008 Institute for Healthcare Improvement and R. C. Lloyd & Associates

50. The Peg Exercise: The Solution!
Objective
To run PDSA tests until you end with only one token (piece of candy) left on the worksheet

51. Peg Game Worksheet PDSA Cycle 1 2 3 4 5 6 7 8
Number of Candies left on the board
What was your theory or plan for making jumps?
What did you learn about this plan?
What will you try in the next cycle? 1 2 3 4 5 6 7 8

52. How Many PDSA Cycles have we run. What did we learn
How Many PDSA Cycles have we run? What did we learn? Could you repeat it Could you explain it to someone else

53. Old Rule / New Rule
Start with a large pilots with an expert devised plan to be tried on a whole unit before spread.
Small scale testing is crucial to learning how to neutralise or overcome barriers
Front line staff opinions generated from small scale testing are essential in creating clarity on process (the how)
Most processes can be “firmed up” in 3 or 4 cycles of testing and in the long run will be faster and have more chance of success than larger scale implementation

54. Old Rule / New Rule
Gives too much opportunity for front line staff who do not necessarily know the science to input into the process
All the testing just takes too long
Getting too many other opinions just confuses the team since most of the time they already know what to do
Look for and fix defects “in state” during initial testing
135all

55. Old Rule / New Rule
Use vigilance and hard work to accomplish the task. This is what I do in my clinical work.
If only every one else worked as diligently as I did there would be no problem
Hard work and vigilance are not sustainable over the long term- don’t give high reliability
A process dependent on hard work is difficult to test for competency and teach to new people

56. He/she who tests wins
Test yourself
Start easy and super small with “small” tests ( 1 patient/1 nurse/1doc)
Build rapidly upon the learning
Build contigencies
Don’t ask permission
Connect to measurement
Just enough data concept
Build an expectation of testing
Leadership connection
Review data regularly

57. QI Primary drivers for improvement Will Ideas Execution
Having the Will (desire) to change the current state to one that is better
Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas
Developing Ideas that will contribute to making processes and outcome better
Will QI
Ideas
Execution

58. Adoption is a SOCIAL thing!
A better idea…
…communicated through a social network…
…over time

59. "Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”
1941, William A. Foster 59