improvement training winterbourne medicines launch

Improving health outcomes across England by providing improvement and change expertise

Quality Improvement Training

Zoë Lord & Carol MarleyImprovement Managers

How are you feeling?

What we’re going to cover

• Improvement models & techniques – Mapping– Measuring – Testing & improving…

• Understanding ourselves and others…Getting the right people involved.

Quality ImprovementService Improvement

Service RedesignProcess Redesign

• But there is a clear structure that we’re going to follow, and we’re going to help you.

• Improvement work is not difficult

• It’s not necessary to start from scratch

• It’s pointless to just tell people to work harder;it’s better to try and work differently

“Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way…if only he could stop bumping for a moment and think of it!”A. A. Milne

“Every system is perfectly designed to get the results it achieves”

Paul BataldenDartmouth Medical School, New Hampshire, USA.

The NHS Change Model

8 components

Aims

Measurements

Change ideas

The Improvement GuideLangley et al (1996)

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make that will result in improvement?

Model for Improvement

Act Plan

Study Do

Testing ideas before implementing changes

PDSA Cycle for Learning and Development

Act Plan

DoStud

y

Act on learning…What is next?

Observe the results… Did it work?

What will happenif we try somethingdifferent?

Try it!

• Ready to implement?

• Try something else?

• Next cycle

• Objective• Questions and predictions• Plan to carry out:

Who? When?How? Where?

• Complete data analysis• Compare to predictions• Summarise

• Carry out plan• Document

problems• Begin data • analysis

Table Discussion

Aims

Measurements

Change ideas

The Improvement GuideLangley et al (1996)

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make that will result in improvement?

Model for Improvement

Act Plan

Study Do

Testing ideas before implementing changes

We are trying to accomplish…

Safe, appropriate and optimised use of medication for people with learning

disabilities whose behaviour can challenge.

We all need to be talking about the same thing…

Can you picture…

A cat on a mat!!

Mapping the Process

“Every system is perfectly designed to get the results it achieves”

Paul BataldenDartmouth Medical School, New Hampshire, USA

• One of the most useful tools in improvement work• Works within organisations and across organisations• Understand current systems• Identify areas to investigate/change/improve - particularly

‘handoffs’, duplication and “why on earth do we do that?”• steps which do not add value for the patient• Identify process waste• Team-building process - helps shared understanding and

building links etc.

Process and Value Stream Mapping

An elephant is like a brush

An elephant is like a rope

An elephant is like a snakeAn elephant is

soft and mushy An elephant is like a tree trunk

Lift receiver

Dial Number

Let phone ring

Say Hello

Have Conversation

Say Good ByeHang up receiver

Simple Process Maps

Lift receiver

Dial Number

Let phone ring

Say Hello

Have Conversation

Say Good Bye

Hang up receiver

Answered?Yes

No

Start \ Finish

Task

Decision or Choice

Direction of flow

Key

Simple Process Maps

What you think it is

What it actually is

What it should be

What it could be

Versions of a process

Value Stream Map

27 minutes hands on time = 91 days

Value Add, Non Value Add and Waste

Value

UnnecessaryWaste

NecessaryWaste

MinimizeEliminateValue Added Activity

Any activity that changes the form, fit, or function of a product/transaction

— OR —Something customers are willing to pay

for

Non-Value Added Activity•Any activity that absorbs resources but

adds no value is a Waste

1st Step - Defining Value

Maximize

A C E

Diagnostic process

Organisational / Departmental Boundaries

Acute Episode

Treatment process

B D

Analysing a Process Map

Analysing a Process Map

• Are we doing the right thing? (Clinical effective)

• Are we doing them in the right order?

• Is the right/best person doing it?

• How co-ordinated is the patients journey?

• What information do we give to patients at what stage? Is the information useful?

Non Value Add (Waste)

• Clues to Non Value Add…

– Rework– Recheck– Return – Retype– Repeat– Recall– Remeasure– Redo

– Bottlenecks– Delay – Waits– Movement – Audits – Handoffs

S.E.C.S

• Simplify

• Eliminate

• Combine

• Sequence

1 Patient has cardiac catheter

4 Tape sent to post room

CHH

5 Tape sent to post room

HRI

6 Tape sent to secretary at

HRI

7Secretary

types letter

8 Letter to doctor for signature

9Letter signed

10 Letter returned to secretary

11 Letter sent to post room

HRI

12 Letter sent to post room

CHH

13 Letter delivered to secretary

14a Secretary request

angiogram

14Letter to surgeon

15 Letter to secretary for OPD

16 Letter to post room

CHH

17Letter to

appointments

18Letter sent to patient

15a Radiographer finds

angiogram

16a Angiograms given to

porter

17a Angiogram delivered to secretary

3 Tape to ward

clerk

2 Letter dictated to

surgeon

19Patient seen

in clinic

20 Patient put on waiting

list

18a Angiogram reviewed by

surgeon

19a Arteries suitable for

surgery

20a Surgeon considers

patient suitable

Example: Referral and Discharge Letters, Cardiac Catheterisation Lab, Hull Royal Infirmary

…after

1Patient has angiogram

2 Data input into

computer

3 Print out data as referral

letter

4 Letter and angiogram

delivered to secretary

5 Secretary makes OPD appointment

6Patient seen

in clinic

1aAngiogram

Tape

Your event…

Hints and Tips:¨ Define the scope

- what process are you going to map?- what are the start and end points?

¨ Decide who is going to be involved

¨ Walk the pathway / process

¨ Start ‘high level’ - then detail where necessary

¨ Focus on the high volume work i.e. ~80% of the work. This is called the ‘Green Stream’

¨ We’ll be helping you!!! Dates in diaries!!!

“To change an organisation,

the more people you can involve,

and the faster you can help them

understand how the system works

and how to take responsibility for

making it work better, the faster

will be the change”

Martin Weisboard

Training and Development Journal

Measurement for Improvement “All improvement will require change,

but not all change will result in improvement”

Aims

Measurements

Change ideas

The Improvement GuideLangley et al (1996)

What are we trying toaccomplish?

How will we know that achange is an improvement?

What changes can we make that will result in improvement?

Model for Improvement

Act Plan

Study Do

Testing ideas before implementing changes

“It feels like…” “I think …”

just isn’t enough!!

If you don’t measure, you won’t know…

• If the changes we make have actually made a difference

• If it is an improvement• How much difference the change has made • How much variation there is in the data/process• Whether you have achieved your aim• If the improvement has stayed in place?

Top tips when starting to measure:

• Seek usefulness not perfection

• Measure the minimum!

• Remember the goal is improvement and not a new measurement system.

• Aim to make measurement part of the daily routine.

We need a baseline!

• To understand current position• Tell a story• Define success • Before and after comparisons• For evaluation and celebration!!!

Baseline examples

• How many people are on your case load:– With challenging behaviour?– With CB and on medication?– With CB and on medication and had a formal

review?

• How many have had review with a clinical pharmacist?

Developing metrics

• We’re going to help you!

• Process measures

• Measure the demand on the service• Measure your capacity • Measure activity• Measure backlog• Outcome measures - reduction in inappropriate medication

A B

Got the data… what next?

Understanding the information Root Cause Analysis

Problem Solving

Data Analysis• Some people love it – but not everyone does!! But it’s

important!! And we’re going to show you how to do it!

• We want to tell a visual story!

List of data

Before and After Intervention Birmingham Nov 09 - Gynae - Sample taken to Result issued

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2

4

6

8

10

12

14

16

Days

NHS Number The Mean (Average) Upper Control Limit Lower Control Limit

Intervention HERE

Data Analysis• Some people love it – but not everyone does!! But it’s

important!! And we’re going to show you how to do it!

• We want to tell a visual story!

• Easy to understand

• A way of demonstrating and thinking about variation – good & bad!

• Statistical Process Control – SPC

What does an SPC Chart look like?Birmingham Nov 09 - Gynae - Sample taken to Result issued

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4

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14

16

Days

Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit

NHS Number

Day

s

SPC Chart to show length of time from prescription to review

Run Chart Birmingham Nov 09 - Gynae - Sample taken to Result issued

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4

6

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Days

Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit

NHS Number

Day

s

Birmingham Nov 09 - Gynae - Sample taken to Result issued

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4

6

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10

12

14

16

Days

Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit

NHS Number

Day

s

SPC Chart to show length of time from prescription to review

SPCBirmingham Nov 09 - Gynae - Sample taken to Result issued

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2

4

6

8

10

12

14

16

Days

Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit

NHS Number

Day

s

SPC Chart to show length of time from prescription to review

SPCBirmingham Nov 09 - Gynae - Sample taken to Result issued

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2

4

6

8

10

12

14

16

Days

Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit

NHS Number

Day

s

SPC Chart to show length of time from prescription to review

AVERAGE

Upper Control

Lower Control

SPCBirmingham Nov 09 - Gynae - Sample taken to Result issued

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2

4

6

8

10

12

14

16

Days

Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit

NHS Number

Day

s

SPC Chart to show length of time from prescription to review

Variation

Time to start asking questions!

Before and After Intervention Birmingham Nov 09 - Gynae - Sample taken to Result issued

-

2

4

6

8

10

12

14

16

Days

NHS Number The Mean (Average) Upper Control Limit Lower Control Limit

Intervention HERE

Root Cause AnalysisProblem Solving

0

10

20

30

40

50

60

70

80

90

F M A M J J A S O N D J F M A M J J A S O N D

Cascading Stratification

Fre

quen

cy

Pareto A

Pareto B

Pareto C

Primary Diagnosis

Ward

Doctor

Kettering General Hospital - Acute myocardial infarction admissions by Ward - Oct 02 to Oct 03

0

50

100

150

200

250

CC

U

MA

U

Alth

orp

ITU

Sur

gica

lad

mis

sion

s

Lam

port

Har

row

den

B

Har

row

den

C Oth

er

Ward transfrred to

Nu

mb

er

0%10%20%30%40%50%60%70%80%90%100%

Count Cum %

Use in combination to validate root causes

Root Cause Analysis• What is it?

– Root cause analysis is the identification of the “vital few” causes that have a material impact on the outputs of a process

• Objectives of Root Cause Analysis– Determine with reasonable confidence what are the current

major causes of problems within a process.

• Why use it?– Too often improvement is initiated based on anecdote and not

rigorous analysis of the facts.– Ensures actions are taken on actual causes rather than

symptoms

Pareto

What does a Pareto look like?

Pareto – 80/20

• Named after Vilfredo Pareto in 20th century who found that 80% of the wealth in Italy was held by 20% of the population

• Helps to focus on the problems which will have the biggest impact if addressed.

• 80% of complaints are about 20% of your services

• Shows relative importance in a simple, visual format.

Fishbone Cause-and-Effect Analysis

Cause 1 Equipment

Cause 2 People

Cause 3 Procedures

Cause 4 Measurement

Cause 5 Communications

Cause 6 Materials

Problem StatementAgree the major

cause categories and attach to the centreline of the diagram

Cause 7 Machines

Cause 8 Methods

Cause 9 Policies

Cause 10 Plant \ Environment

How to construct a fishbone diagram

How can a Fishbone help?

• To help break down a large problem into small elements

• To reveal hidden relationships between causes & effects

• To help identify the root of a problem • To highlight important relationships for investigation • To identify possible data requirements for the project• To help individuals or groups to generate ideas • To identify areas for quick wins

Problem Statement - Why are 51% of patients staying

longer than 5 days ?

Cause 3 ProceduresCause 2 People

Cause 6 Materials \resources

Cause 5 Communications

Cause 4 Measurement

Cause 1 Equipment

No MDT’s

Delays in patient transfer

Transport issues

No hospital wide procedure

No Active discharge planning

Inconsistent recording of ward round requirements

Inconsistent verbal communication on transfer

Transport not available

T.T.O’s not available

Duplication of diagnostics

Limited 24/7 access to diagnostics

Discharge lounge not opened at weekends

No CathLab

POD not working weekends

Work through the main headings drilling down through the causes

We’ve made improvements…

What next?

• Continuous Improvement • Standardisation • Mistake proofing • Sustainability & Spread

We’ve made improvements… What next?

Getting the right people involved an supporting the process of change

Do you like change?

Attitudes to change differ…

Proportionateenthusiasm

Healthyscepticism

Annoyingevangelism

Irrationalobstructionism

Moderateinterest

How do you feel if your not told about changes?

How do you feel if you’re the last to know?

Have you got the right people involved?

• Psychiatrists, nurses, managers, care staff, pharmacists, patients, carers, families, speech therapists, psychologists, commissioners, trust service improvement / project management office, communications team, chief executive, schools, GPs, social services and local authorities …

Attitudes to change differ…

Proportionateenthusiasm

Healthyscepticism

Annoyingevangelism

Irrationalobstructionism

Moderateinterest

Attitudes to change

Proportionateenthusiasm

Healthyscepticism

Annoyingevangelism

Irrationalobstructionism

Moderateinterest

Calming downKeeping in real world

PerspectiveFocussing ?

SupportDirectionFeedback

MotivatingExploring

Evidence of benefit

“Unpacking”Debate (argument)

Selling

Go back to your communication plan…

We all respond differently

• Analyst• Amiable• Social (Expressive)• Driver

Analyst Amiable Expressive Driver

Analytical Patient Verbal Action-orientated

Controlled Loyal Motivating Decisive

Orderly Sympathetic Enthusiastic Problem solver

Precise Team person Gregarious Direct

Disciplined Relaxed Convincing Assertive

Deliberate Mature Impulsive Demanding

Cautious Supportive Generous Risk-taker

Diplomatic Stable Influential Forceful

Accurate Considerate Charming Competitive

Conscientious Empathetic Confident Independent

Fact finder Persevering Inspiring Determined

Systematic Trusting Dramatic Results-orientated

Logical Congenial Optimistic

Conventional Animated

Analyst

The Analyst: Technical SpecialistMay be perceived positively as

May be perceived negatively as

• accurate • critical

• conscientious • picky

• serious • moralistic

• persistent • stuffy

• organised • stubborn

• deliberate • indecisive

• cautious

The Analyst• Places an high value on, facts, figures, data and reason• Sometimes described as analytical, systematic or

methodical• Tend to follow an orderly approach when tackling tasks• Well organised and thorough• Sometimes seen as too cautious, overly structured and

does things ‘by the book’• They view time in a linear (sequential) fashion

How do you communicate

with an Analyst?

Communicating with an Analyst• They want facts, figures and data in the message

• It should be presented in an orderly fashion, with supporting documentation

• Give them time to examine reports etc.

• Written communications can be quite formal and precise, listing key points

Amiable

The Amiable: Relationship Specialist

May be perceived positively as

May be perceived negatively as

• patient • hesitant

• respectful • ‘wishy-washy’• willing • pliant• agreeable • conforming• dependable • dependent• concerned • unsure• relaxed • laid back• organised• mature• empathetic

The Amiable• Interested in & places a high value on, relationships,

feelings, interactions and affiliation with others

• Often described as warm and sensitive to feelings of others, and a loyal & supportive friend

• May be viewed as too emotional / sentimental and too easily swayed by others

• Will often make reference to past events and their relationships over a period of time

How do you communicate

with an Amiable?

Communicating with an Amiable

• Make sure the human dimensions and how people may feel are included

• Let them know who else will be involved• Include past experiences in a similar situation• Written communications can be quite

informal, chatty and friendly.

Expressive

The Expressive: Social Specialist

May be perceived positively as

May be perceived negatively as

• verbal • a talker• inspiring • overly dramatic• ambitious • impulsive• enthusiastic • undisciplined

• energetic • excitable• confident • egotistical• friendly • flaky• influential • manipulating

The Expressive

• Interested in taking people with them, enthusing them with optimism and energy

• Tend to be open with people and willing to make a personal investment

• Generally very good with people• May frighten people by being expressive!• They tend to be poor with detail

How do you communicate

with an Expressive?

Communicating with an Expressive

• They will be looking for the new and the exciting aspects of the message

• Include some kind of innovation to hook the expressive

• Written communications can tend to be vague and abstract.

• They are inclined to be idea orientated and are often quite lengthy in making a point.

Driver

The Driver: Command Specialist

May be perceived positively as

May be perceived negatively as

• decisive • pushy• independent • one man show• practical • tough• determined • demanding• efficient • dominating• assertive • an agitator• risk-taker • cuts corners• direct • insensitive• a problem solver

The Driver• Places great emphasis on action and results• Often viewed as decisive, direct and pragmatic• They view time as here and now, like to get things done

and hate spinning things out• They translate ideas into action, and are dynamic &

resourceful• Sometimes accused of only seeing the short term, and

neglecting long-range implications• Can be seen as too impulsive, simplistic, and acting

before they think

How do you communicate with a Driver?

Communicating with a Driver

• “What are we going to do?”• ‘When are we going to do it?”• Written communications will be brief,

sketchy and crisp.• They may resent having to take the time to

write and will often scribble a reply on the senders original message and return it to them.

Go back to your communication plan…

Today we have covered…

Improving health outcomes across England by providing improvement and change expertise

Next Steps

Next Steps

• Dates in diaries with Zoë and Carol • Complete and return paperwork• Monthly reporting• 6C’s community of practice

• Engage your team• Define your project• Understand your baseline and measures• Patient engagement plans

Remember:

What people should doWhat people think they doWhat people say they do

May not beWhat people actually doUnderstand the real problem before you plan the

solution

Don't make assumptions...

@NHSIQ

enquiries@nhsiq.nhs.uk

www.nhsiq.nhs.uk

Improving health outcomes across England

by providing improvement and change expertise.