1. First Steps in how to do a Quality Improvement Project. Dr S.A.Cullis FRCGP. Associate Postgraduate Dean HEEM. Dr Susan Hadley Programme Director HEEM

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

3. Learning Objectives To learn about Quality and Safety and to understand the basic structure of a Quality Improvement Project. To find out about BMJ quality website as a tool to help To learn where to find more information/resources.

4. Do registrars need to learn this? The Gold Guide says ‘take part in systems of quality assurance and quality improvement in their clinical work and training.’ RCGP curriculum says Understanding how and when to apply tools and metrics to improve the quality of care is a key skill that can and should be learnt during your training, as well as enhanced in lifelong learning

5. Why do we reliably fail? What causes harm to patients? Where should we focus our improvement efforts?

6. Be a good person Train well Maintain good intentions Work hard

7. What is wrong with this plane?

8. Lessons from Human Factors Research ‘You can’t change the human condition, but you can change the conditions under which humans work’ James Reason ‘You can’t change the human condition, but you can change the conditions under which humans work’ James Reason Error is normal... what are you going to do about it? Error is normal... what are you going to do about it?

9. Be a good person Train well Maintain good intentions Work hard Make it easier to do the right thing Make it harder to do the wrong thing Spot & stop inevitable errors Make it easier to do the right thing Make it harder to do the wrong thing Spot & stop inevitable errors

10. So How Can We Improve Quality?

11. What are we trying to accomplish? How will we know that change is an improvement? What change can we make that will result in improvement? The Model for Improvement Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994

12. 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

13. 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

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

15. 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!!

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

17. How to decide what to improve?

18. Significant Event Audit. Pringle’s SEA definition: A process in which individual episodes (when there has been a significant occurrence either beneficial or deleterious) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care, and to indicate any changes that might lead to future improvements

19. Chains of events James Reason BMJ, 320(7237), 768-770 Harm

20. A systems approach From Vincent CA et al. BMJ. 2000;320(7237):777-781

22. Safety Walkrounds™ Try it yourself...

23. The Pareto Principle How not to change everything at once!

24. Making better decisions about priorities Focusing your effort where it matters The Pareto Principle

25. The 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’

26. 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

27. What does it look like? Three categories of interruption (17%) account for 73% of the problem

28. Driver Diagrams How to generate and organise ideas for improvement.

29. Driver Diagrams AIM – an improved system Primary driver 1 Primary driver 2 Secondary driver 1 Secondary driver 2 Secondary driver 3 Secondary driver 4 Secondary driver 5 CP1 CP2 CP3 CP4 CP5 CP6 CP7 AIMPRIMARY DRIVERS SECONDARY DRIVERS CHANGE PROJECTS

31. 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 Generate Change Ideas

32. 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

33. 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

34. Software for driver diagrams – PowerPoint – Dia – Freemind – VUE – MindMeister – MindJet

35. Reliable Design

36. Deliberate reliable design Segment? What’s happening? What’s the priority? What’s going on?

37. eg How do at-risk infants get Vitamin D? Deliberate reliable design – ???

38. Measurement for Improvement.

39. 70% of change fails

41. The traditions of measurement

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

43. 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.

44. What to measure? 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 on patients and the population

45. Balancing measures

46. 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?

47. 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?

48. 48 Measurement for learning

49. 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

50. 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

51. Control charts Statistical process control (SPC)

52. Frequent measures Average line (mean/median) Upper control limit (3 SDs) Lower control limit (3 SDs) 0.13 th percentile 97.4% C.I.

53. Understanding variation

54. The five rules Rule 1: Any point outside a control limit. Rule 2: A run of 8 points all above or below the centre line. Rule 3: A run of 6 points increasing/decreasing. Rule 4: 2 out of 3 consecutive points beyond +/- 2 sigma. Rule 5: A run of 15 points all within +/-1 sigma of the centre line.

56. Software suggestions There is a huge number of software packages which perform analysis for statistical process control. Among them, some of the most accessible are: Very cheap. Baseline www.valuesystemdesign.com/Baseline/Baseline_01.htm Cheap. Winchart prismeurope.co.uk/software/ More comprehensive. Minitab. www.minitab.com Chart Runner. www.pqsystems.co.uk

57. A story about improving reliability in General Practice ALL NEW IMPROVED COMPUTER GENERATED Pathology form

58. The Original Form

59. Adding Information for the Patient

61. Other Examples of GP QI Projects? ST3 project Milton Keynes-see handout. Tackling of long waits for local physiotherapy services, through development of self‐help leaflets for common musculoskeletal conditions, designed in conjunction with practice staff and a specialist.

62. 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.

63. BMJ Quality www.quality.bmj.com

64. Links to Other Useful Resources. http://www.ihi.org http://www.vle.eastmidlandsdeanery.nhs.uk/ mod/folder/view.php?id=15885 http://www.vle.eastmidlandsdeanery.nhs.uk/ mod/folder/view.php?id=15885 http://www.qihub.scot.nhs.uk/default.aspx (this is a link on the VLE to QI powerpoint slides and other useful info. It will soon be updated and moved to a specific QI location on Moodle)

65. GP Primary Care Educator Leads Dr Sue Cullis. APD scullis@nhs.netscullis@nhs.net Dr Susan Hadley. PD susan.hadley@nhs.netsusan.hadley@nhs.net Dr Christine Johnson. christine.johnson@nottingham.ac.uk christine.johnson@nottingham.ac.uk Dr Graham Todd todds@doctors.org.uktodds@doctors.org.uk Dr David Young davidj.young@nhs.netdavidj.young@nhs.net Dr Helen Tallantyre helen.tallantyre@nhs.nethelen.tallantyre@nhs.net

66. Areas Covered by the PCELs Overall Lead- Sue Cullis Leicester, Kettering, Northampton- Susan Hadley & Sue Cullis Nottingham, Lincoln & Boston- Christine Johnson Chesterfield (and North Notts)- Graham Todd Derby ( and Mansfield)- David Young (Mansfield & North Notts- Helen Tallantyre)

67. Looking Forward? Write down 3 things you are going to do as a result of today’s session? And by when are you going to do them? Please share 1 action with the group.

68. “ 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