wednesday 9th december 2015 & wednesday 9th march 2016

‘Kick Start Your Quality Improvement Project’

Learn how to undertake and deliver quality improvement projects

Training for RegistrarsWednesday 9th December 2015

&Wednesday 9th March 2016

1

Programme this morning

2

1. What is Quality Care?2. Problem Hunting

i. 360 Patient Safety Appraisalii. Process Mapping

3. What to change?i. Driver Diagrams

4. How to change things?i. PDSA cycle

5. Measurement for change6. QI Resources

What is Quality Care?

Safe Timely Effective Efficient Equitable Patient - Centered

Problem Hunting….

What Needs Improving?

• Write you own niggle list, but be careful• Or analyse one aspect of patient care

Safe – where are patients being harmed?Timely – how are we wasting time?Effective – what are we doing that does not work?Efficient – how are we wasting NHS resources?Equitable – what’s not fair?Patient-focused – where are patients being forgotten?

Example 1 – Analysing Safety

Example 2 – Analysing Processes

• Process Mapping is the visual representation of a Patient journey

• What ACTUALLY happens, not what should be happening, or you think is happening.

• Any process should be possible to map

Process Mapping

Process Mapping

The box represents the task or activities of the process.

The arrows represent the direction of flow of the process.

If you need to, you can also use a diamond shape to indicate a question, or decision point.

Why Map a Process?

“If you can’t describe what you are doing as a process, you don’t

know what you’re doing.”

– William Edwards Deming

Stages in PM

Map the process

Prioritise

Make it easier to do the right thing

Make it harder to do the wrong thing

Spot & stop errors

Know exactlywhat’s

happening

Deliberate Reliable Design

Processes should be… Standardised for

Testing Training Reliability

Simple – the less steps the less error Safe – sometimes redundant steps

needed

eg How do at-risk infants get Vitamin D?

Deliberate reliable design – ???

Process Mapping - 2 Stages

• Stage 1 - Understand what actually happens to the Patient, where it happens and who is involved.

• Stage 2 - Use the map to identify steps that could be changed.

PM Stage 1 – What actually happens?• How many times is the Patient passed

from one person to another (Hand offs)?• Approximate task time• Approximate time between tasks (wait

times)• Total time taken• Number of steps

PM Stage 2 – Identify problems

Look for any…• Bottle necks or constraints (Queues)• Delays? (Wait for

clinician/consent/results/parking)• Repetition? (e.g. Patient identity check)• Unnecessary travel or movement in the

department. (Patient, staff, kit or notes)• Unnecessary steps?• Inefficient order of events?

Mind the gap !

Look at the whole process,not just the individual steps.

Have a go!

Look at the anticoagulant clinic process map and see if you can come up with improvements

OR

Try and draw a process map. Choose something you think you know well. Swap with neighbour and look for possible improvements.

Helpful resources

• NHS Institute Innovation and Improvement

– An Overview of Process Mapping

• Scottish Health Council – Process Mapping

• NHS Institute for Innovation and Improvement

– Improvement Leaders Guide (Capability)

Problem Found!

But what to do about it?

What should we tackle first?

Introducing driver diagrams

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

AIM PRIMARYDRIVERS

SECONDARYDRIVERS

CHANGEPROJECTS

Help plan group action Bring the team together

www.em.hee.nhs.uk

Avoid silver bullet thinking

www.em.hee.nhs.uk

Avoid blindspots

www.em.hee.nhs.uk

innovate ANDimprove

2004 – 2 Olympic Golds

2008 & 12 – 8 Olympic Golds

2012, 13 & 15 – Tour de France winners

The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together“

David Brailsford, 2012

Philosophy of ‘Marginal Gains’

e.g. take your own pillow (change project; secondary driver, sleep better)

AIM

Improveaccess

Everything you can think of?

Waiting room info, list clinician interests/languages, web info, Rx access (Feel Better Faster), signpost more (WIC/HV/minor inj/Secs/DNs/A&E), Chronic disease training, care planning, review periods, get it right first time, test results processing, teamworking/multiskilling, results line hours, protocols for test results, widen skill mix, BP machine in watiting room, update rpt Rx, pharmacist planning, streamline processes, streamline recalls, education & reflection, up-to-date pt contact details, know what appt is for, pt registration management, Triage, Care planning / pathways, more TelC, emailC, clinical buddies/teams, test results, repeat Rx, forwarding tasks + results, check + update usual GP, results actioned by right person, advance appt booking, reserve list, ask pt who they want, rota in advance, notekeeping w plan + pt info, Consult skills, comp skills, speed reading/typing, forms + equipment, multi-skilling, longer appts, No emerg appts, Test results, Care planning, High risk processes, Referral chase-up, results continuity, streamline processes, streamline recalls, clear up alerts, handling of normal results, self-checkin, fast-track queue

AIM PRIMARYDRIVERS

SECONDARYDRIVERS

CHANGEPROJECTS

Improveaccess

AIM PRIMARYDRIVERS

SECONDARYDRIVERS

CHANGEPROJECTS

Improveaccess

Doctors (capacity)

Demand

Dealing (efficiency)

Appt system

Supply of GP time

Organisation of GP time

Pt help-seeking

Deflecting demand

Creating our own workload

Planning care

Appt system project

GP rota change project

Community education

Waiting room TV

PILS & CDs & DVDs

Feel better faster

Student sick notes

Reception signposting

Test results

Consulting skills

Longer appts

Guaranteed interpreters

Dealing w failed referrals

Chronic disease pathways

Review periods

More TelC’s

Email appts

Continuity

How To Make A Driver Diagram

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

glassesPut

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

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

glassesPut cycling days in diary

Cycling kit out night before

Get rid of Oyster card

Take stairs 2 stone

weight loss in 6/12

Look for patterns

Pedometer

Gym work out 3 days Squash

weekends

No pub weekdays

Take packed lunchLow fat

mealsBuy only

1 sandwich

Water bottle for work bagFruit for

dessert Put away large wine

glassesPut cycling days in diaryCycling

kit out night before

Get rid of Oyster card

Take stairs

Be more active during

the dayDo sport

Drink less alcohol

Substitute lower calorie

foods

Eat less

Marshall the mass of ideas

2 stone weight loss in

6/12

Driver DiagramsWeight loss example

Pedometer

Gym work out 3 daysSquash

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 diaryCycling 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 lessReduce calories

in

Increasecalories

out

Take stairs

2 stone weight loss in 6/12

What Do You Want to Change?In your practice you could…1. Identify an aim2. Come up with lots of ideas – think

smalli. Through team meetingii. Or suggestion box

3. Group them4. Remove duplications/Expand other

ideas5. Identify idea(s) to implement

www.em.hee.nhs.uk

Any Questions?

NHS Model For Improvement

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

What are we trying to accomplish?

The Model for Improvement

Setting the aim: What are we trying to do?

State the aim in SMART terms:SpecificMeasurableAchievableRealisticTime Scale

Example: We aim to reduce the number of prescribing errors that occur by 20% in our GP surgery over the next 4 months.

How will we know that change is an improvement?

The Model for Improvement

All improvement requires change, but not all change is an improvement!

1. Measure a base line2. Ensure that everyone is measuring

the same thing3. Measure after the change4. Plot the changes on a Statistical

Process Control Chart (discussed later)

What change can we make that will result in improvement?

The Model for Improvement

Whole team involvementBrainstormingIdeas on post itsProcess MappingDriver DiagramsSearch for Precedents

What are we trying toaccomplish?

How will we know that achange is an improvement?What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

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 2nd ed, Jossey Bass Publishers, San Francisco

Traditional Approach to Activities

Suggested Approach

P D

P D S AS A

Time

PDSA Cycles

Which is typical of your organisation?

Time saved

© NHS Institute for Innovation and Improvement 2010. All rights reserved. 64

Repeated PDSA cycles work towards the AIM

PDSA

PDSA

PDSA

PDSA

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

Start small

Benefits of this approach

• easier to start• produces better solutions more

quickly• engages people better• reduces waste• easier to continue

Measurement for Improvement

© NHS Improving Quality 2014

Model for improvement

A PDS

A PDS

70

© NHS Improving Quality 2014

7 Repeat steps 4-6

Seven steps to measurement

1 Decide Aim

2 Choose Measures

3 Define Measures

4 Collect Data

5 Analyse and Present

6 Review Measures

71

Step 1 – Decide Aim

Make it SMART

Steps 2 & 3 Choose & Define Measures.

Structure, Process, Outcome & Balancing measures.

What to measure?

Structure Process Outcom

e

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

What to measure?

Structure Process Outcom

e

e.g. Structure indicators…• attributes relating to clinicians (such as certification, training)• midwife to birth ratio • Size of community nursing teams• access to equipment eg, MRI scanners.

Structure Process Outcom

e

What to measure?

e.g. Process indicators…• antenatal assessment <13 weeks• physical checks in people with serious mental illness• structured education for people with diabetes• people with stroke reviewed <6 months of leaving hospital• 7 day follow up after OPMH admission

What to measure?

NICE quality standards…

e.g. Outcome indicators…• Falls• Peri natal mortality• hospital admissions for ambulatory care-sensitive conditions• mortality within 30 days of hospital admission for stroke• emergency re-admissions within 30 days of discharge from hospital• health-related quality of life for people with long-term conditions• patient experience of maternity services• Patient Reported Outcome Measures• Unexpected deaths

Structure Process Outcom

e

What to measure?

Structure Process Outcom

e

o Outcomes are a worthy goalo All have pros & conso We should measure a selection

of all threeVeena Raleigh

Balancing measures

OU

TPU

TS

HUMAN FACTORS

HUMANFACTORS

INTERNAL PROCESSES & PROCECEDURES

INPU

TSEXTERNALFACTORS

Process Measure(s)

Out

com

e M

easu

re(s

)

Balancing Measure(s)

What to measure?

Is it being done?

Is it working?

Unintended consequences?

Stru

ctur

e M

easu

re(s

)

system fit for use?

Steps 4& 5

Collecting , analysing and presenting data.

I use run charts & statistical process

control (SPC)

I know about run charts &

statistical process control

(SPC)

I don’t know about run charts

& statistical process control

(SPC)

121110987654321

TIME12345678910

1211

The distributions arising from a process hide the variation over time

Mean

121110987654321

TIME12345678910

1211

The distributions arising from a process hide the variation over time

The time series data

can tell a different story

Mean

© NHS Improving Quality 2014

What does this data tell us?

Patients treated in April

600

550

610

540

560

570

580

590

2008 2009

85

© NHS Improving Quality 2014

What does this data tell us?

Patients treated

650

600

550

500

450

400

350

300April 2008 April 2009

86

© NHS Improving Quality 2014

What does this data tell us?

This Month Last Month

Given two different numbers, one will always be bigger than the other!

Som

ethi

ng Im

porta

nt

What action is appropriate?

87

© NHS Improving Quality 2014

Plotting the dots - example Run ChartNumber of calls to outreach team (weekly)November 2007 to June 2008

0

No

of C

alls

180

160

140

120

100

80

60

40

20

1st Nov 15th Nov 29th Nov 13th Dec 27th Dec 10th Jan 24th Jan 7th Feb 21st Feb 6th Mar 20th Mar 3rd Apr 17th Apr 1st May

Week

Calls per week Median

88

We have 2 quarterly data points - is this an improvement?

Executive Time Series

0

20

40

60

80

100

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

Months

Som

ethi

ng Im

portan

t

Higher is

better

Are we assuming something like this?

Executive Time Series - linear trend

0

20

40

60

80

100

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

Months

Som

ethi

ng Im

portan

t

But it could be like this ...

Executive Time Series - no trend

0

20

40

60

80

100

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

Months

Som

ethi

ng Im

portan

t

Or this ...

Executive Time Series - seasonal dip

0

20

40

60

80

100

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

Months

Som

ethi

ng Im

portan

t

Or this!

Executive Time Series - one month blip

0

20

40

60

80

100

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

Months

Som

ethi

ng Im

portan

t

© NHS Improving Quality 2014

The Myth of Trends

Upward trend ? Downward trend ?

Downturn ?Setback ?

Turnaround ?Rebound?

Static ?Flatline ?

94

© NHS Improving Quality 2014

Time

Downward trend

Time

Upward trend

Looking for a trend

7 points all in upward direction

7 points all in downward direction

95

© NHS Improving Quality 2014

Looking for a trend

7 points above centre line 7 points below centre line

Time

Below centre

Time

Above centre

96

108

QI Resources

Resources Available

• BMJ Quality programme http://quality.bmj.com/bigwinshttps://www.youtube.com/user/QualityBMJ

• QI Resource websitehttp://www.vle.eastmidlandsdeanery.nhs.uk/course/view.php?id=934

• Each other• HEEM staff

QI Educational Leads• Dr Sue Cullis. APD scullis@nhs.net• Dr Susan Hadley. PD

susan.hadley@nhs.net• Dr Christine Johnson.

christine.johnson@nottingham.ac.uk• Dr Graham Todd todds@doctors.org.uk• Dr David Young davidj.young@nhs.net• Dr Helen Tallantyre

helen.tallantyre@nhs.net

Some of the topics discussed…

Lean technique, Six Sigma, PESTLE analysis, diffusion of innovation, audit, PDSA, SEA, RCA, process maps, fishbone or driver diagrams, logic models, variation, SPC, funnel plots, Swiss cheese model, Pareto principle Miller's pyramid.

Time to plan

112

What small thing niggles you?What tools could you start using?Why?When?What are you going to change?Where?How?How will you measure it?Over what time scale?Who will you need to liaise with?What resources might you need?

HEEM Quality Improvement Forum 2015

https://www.youtube.com/watch?v=vDhfzQ0JkFY

Happening again in 2016!Come to present you QI project….….and see others and get inspired!

What had over 100 posters, 75 abstracts, 2 keynote speakers, 4 workshops, 9 presentations, 6 award winning improvement projects  and 350 delegates?

SAVE THE DATE! Health Education East Midlands are pleased to announce that the next Quality Improvement Forum will take place on 29th June 2016 @ the Kube, Leicester Racecourse in Oadby, Leicester.

Key HEEMQIF16 activities for your diary:• Forum programme cascaded -  w/c 14th December 2015• Call for Quality Improvement Projects Abstracts – w/c 4th January

2016• Call for bookings & workshop bookings open – w/c 4th January 2016• Abstract submissions close – w/c 28th March 2016• Bookings close – 31st May 2016• HEEMQIF16 – 29th June 2016

Join in the conversation on Twitter using @EastMidsLETB #HEEMQIF16 #loveourlearners  

Health Education East Midlands Quality Improvement Forum 2016 HEEMQIF16

“The most important single change in the NHS in response to this report would be for it to become….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