dr john bibby frcgp gp & deputy medical director nhs bradford
TRANSCRIPT
Dr John Bibby FRCGPGP & Deputy Medical Director
NHS Bradford
Cedar Court Hotel, Thursday 4th March, 9am – 5pm
9.15 – 9.25 Welcome and Introduction
9.25 – 10.00 Key concepts in patient safetyRebecca Lawton highlights the results from the online learning module
and refreshes the key concepts in patient safety
10.00 – 10.45 Tools Marketplace An opportunity to obtain further information about different types of
patient safety tools. Gerry Armitage will provide a brief introduction and overview.
10.45 – 11.00 Coffee
11.00 – 11.30 How to analyse your safety problem John Bibby describes a range of improvement tools that can be applied to
help you tackle an identified safety problem
11.30 – 12.30 Team time 1: Applying improvement tools to your safety problem...with support from improvement coaches, and, if available, clinical
governance lead
12.30 – 13.30 Lunch
13.30 – 14.15 Peer review time – meet up with another teamA facilitated exchange time for teams to meet up with another team
14.15 – 14.45 Measurement for improvementJohn Bibby on why measurement is important and how to identify
measures
14.45 – 15.00 Using the Blog/Log to record improvementContinuing sharing your journey with the other teams on this programme
15.00 – 16.30 Team time 2: (NB: Tea is taken during this session) Part A: What measures will you use to measure improvement?
Clarify and finalise the measures for each team – supported and facilitatedPart B: Team action planning
16.30 – 17.00 Plenary review of the day, next steps and close
AIMSKey ConceptsTools & Techniques for your safety IssueTime to apply learningPeer sharing
Select Topic
Expert Reference
Panel
Develop Framework & Measures
Pre-Work
LS 1
P
S
A D
LS 3LS 2
Adapted from © 2001 Institute for Healthcare Improvement
P
S
A D
The Collaborative Process: At-a-Glance
AP1 AP2
Types of Support(On-Site) E-mail Phone Handbook Assessments Measurement & Data
(The Collaborative Process & “collaboration”)
Orientation Event
Reflecting on the on-line learning
Rebecca Lawton
Error inevitabilityStroop task (How might this effect increase errors in
your work?)Recent research commissioned by NHS CFH found a
0.33% error rate when selecting a drug product from lists containing ‘look-alike, sound-alike’ names.
Misreading of numbers due to close proximity of preceding words e.g. Propranolol 60mg
Attention task (In what circumstances are errors like this more likely to occur?)Drug round – tired, distracted, high workloadRoutine observations – when task performed without
thinking, mental workload high
Can you spot the difference?
Error inevitability (continued)Dual task performance (How often do you perform
more than one task at the same time requiring the same processing route e.g. auditory, visual……)
Biases in decision makingDecisions in a social context (think about how your
actions might affect others’ decisions)Decisions in an emotional state (think about how you
feel and how this might affect your decision)Decisions under time pressure, sometimes without the
training or expertise (does the environment support good decision making – e.g. is information readily available)
MCQSome knowns Q2 86% of people know that
whether or not an incident results in harm it should be reported
Q7 Only 20% of people believe that addressing gaps in the individual’s competence is the most effective way to deal with an error
Q10 76% of people are aware of the stable nature of personality – not very amenable to change
Q12 80% of people recognised that deference to authority was not useful for ‘effective team communication’
Some gaps in knowledge Q3 45% of participants
underestimated the prevalence of adverse events and the costs of these events
Q5 Patient accidents are the most frequently reported patient safety incident (29% correct).
Q8 38% recognised that distractions and interruptions are most likely to cause problems in the performance of routine tasks that are well learnt
Q1 25% of participants think that when harm to a patient results from their care this is professional negligence
Some take home messagesErrors are frequent, but they don’t always
result in harm and sometimes harm occurs without any error
We human beings make errors because, in evolutionary terms, we have not had time to adapt to our environment
What is reported is not always a good indication of what is occurring out there
We need to make things easier for ourselves by making our environment support our performance
Case studiesDesigned to take you through the cycle of:
Identifying the nature of the patient safety problem
Developing potential solutionsConsidering the measurement of change and
the implementation of the solution
EvaluationSafety culture measure
On-line learning module
Gerry ArmitageBradford Institute for Health Research
Contextualising the toolCommunication
Crew Resource Management
Checklists
The case of ThomsonflyThomsonfly
Crew Task Management Operation
BriefingsOutlines Plans & DifferencesAllocates TasksSeeks InputChecks Understanding
Situational AwarenessThorough Pre-flight PreparationStays Ahead & Updates Plans Makes Contingency PlansKeeps Broad Perspective
Professional StyleRelaxed & Professional ToneAspires to High PerformanceConscientious & FlexibleSelf-Aware & Seeks Feedback
TeamworkBalances Rank AuthorityFlexible & Shows RespectActively Monitors & SupportsThinks independently
WorkloadRecognises High WorkloadTakes or Makes TimeDeals with Overload / PrioritisesAvoids Distraction & Distracting
Aircraft HandlingSafe, Efficient, ComfortableAutomatic / Manual FlightNon-Normals / EmergenciesManages Errors
CommunicationShares Information / IdeasActively ListensAssertive when RequiredAdmits Mistakes & Doubts
DecisionsIdentifies Problems / IssuesInvolves Others if NeededEvaluates OutcomeUses Structure in New Situations
Applied KnowledgeTechnicalUse of ChecklistsOperational / SOPsCompany Policies
Market PlaceSix ‘tool stations’:Six ‘tool stations’:Rachael – leadership/cultureJohn – clinical decision-makingRebecca – human factorsGerry – Communication (SBAR, Medrecon,
Checking)Beverley – Communication (handovers/care
bundles)Glen – Bar coding
COFFEE
How To Analyse Your Safety Problem
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 ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done?
Langley G, Nolan K, Nolan T, Norman C, Provost L, (1996), The improvement guide: a practical approach to enhancing organisational performance, Jossey Bass Publishers, San Francisco
What hunches do we have? What can we learn as we go along?
Using The Improvement ModelIntention must be to improveSpecific aimsMeasurement to know if achievedIdeas for Change
from experts, science, theory, experience, hunches
Change testing/reflecting & learningPDSA cycle describes in essence inductive
learning – the growth of knowledge through making changes and then reflecting on the consequences of those changes
Tools For Defining The ProblemRoot Cause Analysis (5 Whys)Gap AnalysisProcess MappingIshikawa (Fishbone)Gathering InformationPareto AnalysisBrainstormingAffinity diagramNominal group technique & multi-votingTree diagram
And more.....
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Process MapsPrinciples of Redesign
Understanding Systems“Every system is perfectly designed to get the results it gets.If we want better outcomes, we must change something in the system.To do this we need to understand our systems.”
Don Berwick.
What Is A System?A System is
A collection of structures, processes and patterns
Organised around a purpose
Elements Of A System
EquipmentFacilitiesDepartmentsCommitteesGroupsRoles
Patient pathways & journeys
BehavioursConversationsClinical outcomesWaiting timesReferral rates
SYSTEM
STRUCTURE PROCESS PATTERN
What is a Process Map?
Process maps are:Simple and effective ways of visualizing and
understanding a processValuable and unique quality improvement
toolsWaste management toolsEveryone involved can take part in improving
the process
where does it start ?
where does it end ?
• Start and End must be clearly defined
• Scope must include area(s) needing improvement
How To Process MapWork as a single groupAll stakeholders presentUse a sheet of wall lining paper Map each step using Post-it™ notes (with sellotape )
Start from one end of the process and work forwards/backwards
Focus on what happens 80% of the timeAdd estimates of time for each step & between
steps
Symbols and Shapes
Activity Steps – Yellow Post its
Start and end steps – Coloured Post its
Decisions – Different Colour Post its
Connecting the steps – Black or red pens
PERSON ACTION
Equipment?Place?
PERSON ACTION
Equipment?Place?
Who does what, where, with what and to whom?
Cluedo!
START FINISHPrescriptionRequest
PrescriptionProduction
PrescriptionIssue
WARNING ! WARNING ! Ensure you keep thinking of what really
happens in the current processNot how you’d like it to be!Process maps are NOT flow charts or
algorithmsFocus on what happens to 80%
of the people 80% of the time
Analysis Of Process Map 1How many steps are there for the patient?How many “Hand offs” are there?Approximate time for each step? “Task time”Approximate time between steps? “Wait time”Approximate time between First and Last step?When does the patient join a queue? How many steps don’t add value to patient?What do patients / staff complain about?
Analysis Of Process Map 2For Each Step Ask:
Batching?Can it be eliminated?Can it be done in some other way?Can it be done in a different order?Can it be done somewhere else?Can it be done in parallel?Can any “Bottlenecks” be removed?Is it being done by the most appropriate person?
How many steps in your process?How many hand-offs?How many steps do not “add value”
for patient?Where are possible delays?Where are major bottlenecks?
HNVDB
Consider how long it might take to get from one step to another
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Define The ProblemRoot Cause Analysis (5 Whys)
WHY?
WHY?
WHY?
WHY?
WHY?
37
Define the problemIshikawa (Fishbone) Diagrams
Define the problemIshikawa (Fishbone) Diagrams
PPPP
People Place
Procedures Policies
© 2004 Institute for Healthcare Improvement
Define The ProblemBrainstormingPreparation Ground RulesProcessing the
ResultsMultivoting
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The Pareto Principle‘The 80-20 Rule’‘The Law of the Vital Few’For many phenomena,
80% of the consequences stem from20% of the causes
Observation that 80% of income went to 20% of the population
Vilfredo Pareto, 1906
Reasons why I am lateAlarm IIII IIII IIII 14
Toaster Fuse IIII 4
Slow Kettle I 1
Reading Paper IIII IIII IIII IIII IIII IIII IIII IIII II 42
Talking to Spouse III 3
Late Night IIII I 6
Computer Failed Login II 2
Emergency 0
Cold Shower IIII IIII IIII IIII IIII 24
Interruption IIII I 6
Rank Order the CausesReading Paper 42
Cold Shower 24
Alarm 14
Late Night 6
Interruption 6
Toaster Fuse 4
Talking to Spouse 3
Computer Failed Login 2
Slow Kettle 1
Emergency 0
Pareto Chart: Causes Of Late StartLate Starting
0
10
20
30
40
50
60
70
80
90
100
1
Causes
Perc
en
tag
e
Reading Paper
Cold Shower
Alarm
Late Night
Interuption P/N
Toaster
Spouse
Computer
Kettle
Emerg Visit
Basic Safety Principles So how do we design patient care
processes to prevent error?Automate when appropriate – include use of forcing
functionsStandardise – reduce reliance on memoryUse checklistsReduce the number of steps and handoffsAdd redundancy (double checks) for high risk processes
Team Time 1
Applying improvement tolls to your safety problem
LUNCH
Peer Review Time
Your chance to meet up with another team
Measuring For Improvement
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 ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done? What hunches do we have? What can we learn as we go along?
Langley G, Nolan K, Nolan T, Norman C, Provost L, (1996), The improvement guide: a practical approach to enhancing organisational performance, Jossey Bass Publishers, San Francisco
Measurement
“All improvement involves change BUT not all change is an improvement!”
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Measurement
“Without measurement it is impossible to know whether
you have improved.”
Types of Measurement Measurement can be split into the type of measure used:
Structure , Process, or Outcomes measures. Learning measures are also important particularly when culture is important
Measurement can also be split into the reason why you are measuring:
• Research • Performance Monitoring • Quality Improvement
Types of Measurement The 3 types of measures used in quality work:
Structure: Physical equipment and facilities
Process: How the system works
Outcome: The final result, achievement
Structure and process are easier to measure;
outcome is more important.
DefinitionsStructure is an easy concept to define, it is the
physical plant & people ( e.g. buildings, equipment, staff)
Process and Outcome are a little more complicated to define.
Outcome measures are the most important but don’t forget the way care is given and what patients’ experience is crucial . A “great outcome” but with a patient feeling bewildered and disempowered is not good care
Measurement for ImprovementProcess:
I. How the healthcare is provided
II. How the system works
III. What happens to patients undergoing care
OutcomeI. The result of the intervention
Proxy MeasuresBecause healthcare is often complex and the results may take
years to be apparent outcomes measures can’t always be directly measured. Hence proxy measures are used.
Proxy measures are usually process measures used in place of an outcome ( eg HBA1C level as a measure of diabetic care)
Proxy measures are used when you can’t directly measure what you need to. The best proxy measures are those that have been shown ( through research) to lead to the outcome that you desire
The answer to this question will guide The answer to this question will guide your entire quality measurement journey!your entire quality measurement journey!
Improvement?Improvement?
Judgment?
Judgment?Research?
Research?
“The Three Faces of Performance Measurement: Improvement, Accountability and Research”
Lief Solberg, Gordon Mosser and Sharon McDonald
Journal on Quality Improvement vol. 23, no. 3, (March 1997), 135-147.
“We are increasingly realizing not only how critical measurement is to the quality improvement we seek but also how counterproductive it can be to mix
measurement for accountability or research with measurement for improvement.”
The Three Faces of Performance Measurement
Aspect Improvement Accountability Research
Aim Improvement of care
(How?)
Comparison, choice, reassurance, spur for
change
New knowledge
(What?)
Methods• Test Observability
Tests are observable No test; merely evaluate current performance
Test blinded or controlled tests
• Bias Accept consistent bias Measure and adjust to reduce bias
Design to eliminate bias
• Sample Size “Just enough” data, small sequential
samples
Obtain 100% of available, relevant data
“Just in case” data
• Flexibility of
Hypothesis
Hypothesis flexible, changes as learning
takes place
No hypothesis Fixed hypothesis
• Testing Strategy Sequential tests No tests One large test
• Determining if a Change is an Improvement
Run charts or Shewhart control charts
No change focus Hypothesis, statistical tests (t-test, F-test, chi
square), p-values
• Confidentiality of the Data
Data used only by those involved with
improvement
Data available for public consumption and review
Research subjects’ identities protected
Measurement for SafetyTo improve safety we need to alter behaviour and
culture.
To this end Quality Improvement measures are the most successful.
… is a description, in quantifiable terms, of what to measure, and the steps to follow to measure it consistently
It gives communicable meaning to a conceptIs clear and unambiguousSpecifies measurement methods and equipmentIdentifies criteria
An Operational Definition
How do you define these concepts?
A “fair tax” A “tax loophole”
Rural/Urban/Suburban The “rich”
The “poor” The “middle class”
A “good vacation” A “great movie”
Getting the country “moving” again
Failure to develop a clear Operational definition often leads to confusion and misunderstanding
How Many Measures Do You Need on your Dashboard?
There are many things in life that are interesting to know.
It far more important, however, to work on those things that are essential to quality than to spend
time working on what is merely interesting!
The challenge, therefore, is to be disciplined enough to focus on the essential (or vital few) things and set aside those things that might be interesting but trivial!
Focus on the Vital Few!
▲Simple
▲Clearly Defined
▲Continuous Measurements
▲Continuous Analysis
▲Value Adding
Quality Improvement Measurements
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 ImprovementUnderstanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
Measuring processes and outcomes
What have others done?
Langley G, Nolan K, Nolan T, Norman C, Provost L, (1996), The improvement guide: a practical approach to enhancing organisational performance, Jossey Bass Publishers, San Francisco
What hunches do we have? What can we learn as we go along?
71
Presenting Your DataKeep it simpleOne graph,
one messageUse run charts or
control chartsCharts are easier to
assimilate than tables
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I have a hunch….
Let’s test it
Developing & Testing For Change
The PDSA Improvement Model
Hunch
TestReflection
Next
PLAN
STUDY
ACT
DO
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Developing Improvement Culture
PDSA
ProblemIdentified
PDSA
PDSA
PDSA
PDSA
PDSA
Increasing Team Intellig
ence & Awareness
Change in Team
Culture
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What Should A PDSA Look Like?Objective
Define the problemWhat are you trying to achieve?
PlanWho, what, where, when?Measurement
DoJust do it!
StudyWhat worked? What didn’t?
ActNext steps
Write It
down!
Using the Blog/Log
The green TAPS website For further information see pages nn – nn of
the TAPS HandbookYour Improvement Coach will send you an
individual login to update your team progress
Team Time 2Part A
What measures will you use to measure improvement?
Part BTeam Action Planning
Next Steps
Complete evaluationsProvide Improvement Coaches with your measures
Login to green TAPS website to share and update team progress