Agenda

Part 1: The benefits and limits of Top Down ChangeLessons learnt from establishing and managing the National Clinical Programmes

Part 2: Relearning how to use improvement tools in health careMeasurement: Hip Fracture Pathway & ECHO Utilisation Mapping patient flow: Dementia Pathway Influencing change: Chemo Drug Savings

Part 3: Observations on teaching clinicians QI RCPI Diploma in Leadership & Quality

Part 4: Sustaining change Building a Directorate Model that imbeds continuous improvement

Close: 5 years “Learning” on a page

Process mapping 410-411

Identifying waste Measuring Variation

Illustrating

•Run Charts (Chp 2 & 3))

•Pareto charts -436-437

Stakeholder Management (Chp 8)

Communication planning (Chp 8)

Influencing styles

Data analysis

Flow analysis

Change Management

5% 95%

Key Improvement tools

Q: Why do we measure?

A: To influence behaviour

In Health care,

the Art of measurement

is as important as

the Act of measurement

Students use of time 12hrs before 15 page essay due

Formating page

Making cover page

Skimming research notes

Crying due to fear of

failure

Writing

Facebook

Charles Joesph Minard's graphic depicts Napoleon's Army's march from Paris to Moscow.  The width of the gray striped area is the size of the Army going to Moscow, placed over a geographic map.  Notice how the width of the band shrinks, especially when crossing rivers.  The solid black area/line reveals the size of  the Army returning to Paris.The bottom  line graph displays the temperatures encountered on the return. French casualties in Moscow were light.  Yet the Army was consumed in the march.  Only 10,000 of the original 432,000 survived.

Measures

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx

Yo = f (X1, X2, X3, …………….Xn ) But Yb

Measure & illustrate “Y”

- the measure of your aim

Run charts

Yo = f (X1, X2, X3, …………….Xn )

May-Aug 2012 average activity (No. of Patients seen)

Individual activity May-August 2012

13

Distributione.g. Avlos

No. of patients experiencing a level of care outside the desired standard

A

Frequencye.g. No. of Patients

Aim B

Why is understanding Variation important

Hospital A & B have the same average performance

But patient experience in Hospital A is much more varied than in hospital B

Measure & illustrate “X”

- the causes of variation

Bar & Pareto charts

Yo = f (X1, X2, X3, …………….Xn )

Reasons for Delays Theatre 10/11: 5/8/14 to 14/8/14

16

Reasons for delays through out the Day - Theatre 10 & 11Within our control Vs not in our control

Illustrating causes of variation: Pareto & Bar Charts

X1 X2 X3 X4 X5 X6 X7 X8 X9 X10

Y = f(X1, X2, X3, X4, X5……Xn)

Which is the critical X – the factor that causes the greatest level of variation?

Fix the critical X first – then move on to PDSA’s for other Xs

Count of frequency of

reasons

Reasons as a % of total count of

reasons

1. Reorder data with the most frequent reason at the top 2. Calculate what % each reason type is of total reasons 3. Create Bar chart of count of reasons 4. Overlay with line chart which accumulates % of reasons

Reason for delayed discharge Count of reason

Home care package decision 5House being adapted 1Fair deal delay 25Medical Complications 5Familly decision awaited 11No response from Physician 6 53

Frequency%100%

90%

30%

70%

50%

80%

60%

40%

20%

10%

30

25

15

5

20

10

Measurement Plan

Measure title X or Y

Operational definition Data source Sample size

Who collects?

When? How? Display type?

Medication error

Y An adverse (drug) reaction is a response to a medicinal product which is noxious and unintended

Medication error reports

30 incidents

Ward nurse

Start 1/5/14

Review reports end of week

Run Chart showing trend by day

Bringing “X” & “Y” together - to tell a story ”

Hip Fracture Pathway

117Hrs :Echo requested by Anaesthesia

59Hrs: Ortho. awaited cardiology RV

72 Hrs: NOAC, rivaroxiban held 66 Hrs:

Medically unfit

98Hrs: MR within 24hrs, waited for bone scan

77Hrs: No Reason logged

65 Hrs: No Reason logged

Reasons for variation can be hidden

Note: Times were an ECHO test was done but the report was not written up till hours later have been excluded as they would eschew the data incorrectly .

Actual utilisation rate = 65% (Two machines)The level of variation is +/- 12% (Note the third machine is not used)

CalculationThe Actual Utilisation time is calculated based on: The recorded total time for patients in and out plus the time to complete the ECHO report. Where there was no time recorded or there was a significant gap between doing the ECHO test and completing the report the median time (17 Mins to test, 11 Mins to report) was used instead

The Potential time was estimated at 13 Hrs for the two machines per day – formula below

Model for estimating potential utilisation time

Work day (8:30-16:30) 8 Hrs

Less Lunch 1 Hr

Breaks x 2 30 Mins 01:30No. of Hrs if one machine utilised 100% of time 06:30

X2No. of Hrs if two machines utilised 100% of time 13:00

Consequences of variation

• Wait list for other outpatient ECHO referrals = 800• Patient safety• Delayed care = impaired outcomes

• Patients kept as In Patients just for ECHO = Bed days lost = ? • Anecdotal 1 patient = 7 Days

• Delays in access to surgery and theatre late starts? • Hip Fractures • Theatre 10 & 11 late starts

• ECHO technician team working through lunch and risk of general burn out

• Combination of unstructured work and environment impacts motivation of key staff

• NOTE: Patients do not experience delays waiting outside the ECHO room – (1 exception due to miscommunication between Secretarial staff & ECHO team)

ECHO/ECG Technician WTE & Competency

• Key points:• WTE at 76% of capacity • Approval to fill open vacancies

but if not skilled new joiners will require training

• Approval for HCA – HCA will improve work environment but not improve capacity significantly

• 68% of available team not trained in ECHO – prevents rotation between ECG & ECHO plus over reliance/preassure on Chief Technician to both train and do ECHOs

• 24% of total WTEs (12.5) can do ECHOs unsupervised or with minimum supervision

45 Accurate ECHOS are completed per day (8:30 – 9:30)

Primary Drivers Secondary Drivers

Motivated staff

The number of ECHO machines available

The level of demand for the service

Optimising available time

- Work environment - Work load - Staff rotation - Recognition

- Scheduling

- Cardio Clinic demand - Other OPD demand - Inpatient demand

The number of fully trained technicians available

Reasons for varition: ECHO Driver Diagram

• The number of vacancies • The level of experience of

new recruits • The quality and pace of

training

Target Areas of improvement

• Forecasting demand e.g. 25 to 35% of Cardio Clinic patients require Echo

• Ability to control inappropriate demand using agreed referral criteria

• Standardised Scheduling practice

• CVIS • Adequate notice to

inpatients • Porter availability to bring

inpatients to ECHO Dept

• HCA to assist with patient prep

• Area to have lunch • Ability to take scheduled

breaks • Team working & support

from Consultant team • CVIS System

Effective leadership & management

- Effective Cardio team meeting

- Visibility of variation - Operations & change

management skills- Clinical Leadership

• ECHO dashboard• Multidiscipline operations

management meeting• Continuous improvement

Vs Ad-hoc management

Key reasons

Scenario 1: Afternoon Cardio OPD Clinic

Actual Patient arrival times Allocating these patients to nearest “25”minute scheduled slot

Conclusions: •Staff would have been able to take breaks•17 Slots would have remained unfilled – approx 50% of capacity •Only one Cardio patient would have had to wait for a significantly longer period outside the ECHO room

Actual number of ECHOs completed 5/8/14 - 25/8/14 (15 Days)

Potential output over same period (15 days) If daily target

met

Sustainability

Module 1: Measuring variation (Y=f(X1.X2.X3.X4……..Xn)

Mean CL: 17.48

-12.66

47.63

-20.00

-10.00

0.00

10.00

20.00

30.00

40.00

50.00

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Y=

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X1 X2 X3 X4 X5 X6 X7 X8 X9 X10

8.30 Aim

Actual Start timeTime axis

Day of week

Month BarCan be widened or narrowed

Filter options: By Speciality, Theatre or Day of week

Reasons for delay List of actual start times

Electronic dashboard showing Y & X real time

Process mapping 410-411

Identifying waste Measuring Variation

Illustrating

•Run Charts (Chp 2 & 3))

•Pareto charts -436-437

Stakeholder Management (Chp 8)

Communication planning (Chp 8)

Influencing styles

Data analysis

Flow analysis

Change Management

5% 95%

Key Improvement tools

Process mapping symbols

Process mapping symbols and steps

Receive referral

Indicates the start point (trigger) of a process & the end point of a process (final output)

Schedule appointment

Describes each process step (verb noun construction)

Is ventilation required?

Yes

No

Describes decision points

A

Used to link a process that flows on to second page

TRAINING PENSIONS PROCESS EXAMPLE

Pro

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2. SortPost

1 Post received3. Distribute

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5. Is all Infopresent ?

4. ReviewForm

7. EnterContribution

details

6. RequestInformation

No8. Is customer

eligible?9. Send

NotificationNo

10. Set upPayment

11. Sendnotificationof payment

Yes

12. Put awayclaim

Swim lanes – one per role or team. Used to illustrate who does which step and where the hand off occurs

Process mapping stepsIdentify the teams/roles involved in the process(1)Draw a swim lane for each role/team (2)Identify the start point (trigger) and end points (3)Draw start and end symbols in the appropriate swim lanes (4)Identify the process steps and link them using arrows (5)Discuss process issues / opportunities to improve process as you create the map(6)Document map and issues & validate with users

Process title

A

Process mapping – Key lessons

• Do Observation 1st • Map the pathway through individual interview • Log issues as you go along• Hold a meeting to validate map & suggest improvements • Hold sub meetings to tease out detail design of each solution – using map to

“pedantically” facilitate the discussion • PDSA tests as you go – don’t do big bang implementation • Complete “to be” design map and convert to SOP

KEY point• It’s the structured conversation you have while mapping rather than the map itself

is of vale. • A map with out a log of issues and suggestions is of no value • Mapping is an art not a science

Dementia Scheduled & unscheduled pathway 1. carers in crisis have little

alternative to going to ED - phone support

2. ED is not the appropriate place to manage carers in crisis –

- rapid access crisis clinic - carer Education programme required

Dementia Scheduled & unscheduled pathway 1. Difficult to identify quickly if

previous diagnosis of Dementia exists. Community history of patient is not available - PAS system Flag - Can MRN number be used to link to Old Age Psych patient record?- Introduce “this is me” form

2. No Triage Protocol for Confused/ Delirium patients - Agree Triage Protocol

3. Assessment for Delirium/ Cognitive impairment not part of standard Triage/ED Assessment bundle – single short test to be incorporated in ED Assessment

4. No specifically designed assessment Area - Identify and furnish assessment area

5. Not all staff trained in management and assessment of Confused patients – nurses , HCAs, specials etc – Design awareness training

Dementia Scheduled & unscheduled pathway

• Doesn’t appear to be a clear pathway for previously diagnosed Dementia patients who are admitted - agree pre diagnosed dementia pathway - Is a Dementia specific team required/

Process mapping 410-411

Identifying waste Measuring Variation

Illustrating

•Run Charts (Chp 2 & 3))

•Pareto charts -436-437

Stakeholder Management (Chp 8)

Communication planning (Chp 8)

Influencing styles

Data analysis

Flow analysis

Change Management

5% 95%

Key Improvement tools

9 out of 10 change project success factors are people related

Top 10 Success Factors

% of 500 organisations

Ensuring senior management

sponsorship 82%

Treating people fairly 82%

Involving staff 75%

Giving quality communications 70%

Providing sufficient training 68%

Using clear performance measures 65%

Building teams 62%

Focusing on culture/skill changes 62%

Rewarding success 60%

Using internal champions 60%

Source: iibm Mori Survey 1997

Why is Change Management important ?

Flattening the change curve

High Expectations

Realisation of effort and complexity

Despair

Light at the end of the tunnel

Stak

ehol

der

Per

cept

ions

Change Implementation

—Unmanaged Change—Managed Change

Better than beforeWith effective

Implementation++

--

HighLow Medium

Support for change

Lev

el o

f in

flu

en

ce

High

Medium

Low

Influence mapping

Stakeholder Initial support

Level of influence

Key Concern Steps to getting buy in

Pharmacy H H Fear Constant communication & reassurance

Management L H Other priorities Communication & data; ownership (made to feel part of solution) – Its about money

CNS Staff L H “Waste is not part of our responsibility”

Constant communication – Its about safety

Patients L H Extra visits Communication and improved service, improved care

Consultants L H Unaware of data and significance

Data

Getting buy-in – Lisa’s project

Transactional Analysis

NP

A

Nurturing Parent – Provides support, non-judgemental acceptance, and assists in healthy growth

Critical Parent – Prescriptive, tells, obsessed with rules, judgemental, authoritarian, discounting, divisive

Adult – Does clear thinking, questions, is assertive and generates options to help with problem solving, planning, and productive procedures

Innovative Child – Generates ideas, comes up with creative solutions, sees things from different perspectives, open minded, is fun to be with, creates energy

Rebellious Child – Doesn’t obey/follow rules and procedures. Rebels against any form of authority. They send I am OK, you are not OK messages

Sulking Child – Submissive. Feels and acts like a victim. Sends you are OK, I am not OK messages.

CP

IC

RC

SC

Agenda

Part 1: The benefits and limits of Top Down ChangeLessons learnt from establishing and managing the National Clinical Programmes

Part 2: Relearning how to use improvement tools in health careMeasurement: Hip Fracture Pathway & ECHO Utilisation Mapping patient flow: Dementia Pathway Influencing change: Chemo Drug Savings

Part 3: Observations on teaching clinicians QI RCPI Diploma in Leadership & Quality

Part 4: Sustaining change Building a Directorate Model that imbeds continuous improvement

Close: 5 years “Learning” on a page

Observations about training Clinicians in QI

• Realising they needed a “babel fish” to understand what I was saying – Keep language/ terminology simple

• As a non clinician I was never going to get over the credibility gap – Front training with Clinicians ( Train the Trainer training)

• Expose them to what is possible by having speakers from other hospitals with a QI culture e.g. Cincinnati Hospital

• Use SCYPE so they can connect virtually to the class room • Coaching is key – training alone won’t build confidence – use Web meetings to coach • Clinicians need time to absorb and adjust there mind set – Intensive sessions over

long period seems to work – it’s a form of therapy – the light goes on at different timed for different people

• Strong focus on leadership and self reflection – they need to vent and articulate anger / frustration – but bring them back to believing they can make a difference

• Mantra of making one difference to one patient – works – steer them away from curing world hunger

• Make change fun – it increases the chances of success – don’t be afraid to encourage them to be creative

• Back at base – regular lunch and learns seems to be better than class room courses

Understand the problem 1st choose the method second

1 Organisational Fundamentals are present

e.g. defined pathway objective, Metric(s), clear accountability, scheduled performance review meeting, (Micro Systems)

2 Flow standardised

e.g. documented SOP, guideline, algorithm, ICP.

3 End to end Flow efficiency

e.g. Lean review

5 Flow defect free

e.g. 6-sigma review

6 Disruptive innovation

when capacity is optimised & change is required to meet demand

Pathway/ Process maturity

Low

High

Quality Safety & Capacity improvement

Level of analysis required High

4 Reliable patient centred care

e.g. IHI – QI Method and Reliability theory

High Reliability