How do quality improvement (QI) tools and methods contribute to

healthcare improvement?

Cathy Howe, Julie Reed, Derek Bell

NIHR CLAHRC for Northwest London

CLAHRC NWL Approach

Quality Improvement Quality Improvement

Methods

Patient and Public

Involvement Engaging Patients and Staff

ResearchRigorous Design and Use of

Data

Education Training, Support and

Collaboration

A collision of different worlds…

NIHR CLAHRC For Northwest London

Health OutcomesPatient

Experience

Improve health outcomes and patient experience through delivery of clinically effective care.

Primary aim:

4 Rounds: 21 Projects over 55 Sites engaging

over 500 NHS staffsystematic approach

CLAHRC NWL AchievementsBeneficial impacts on care quality, outcomes, experience and costs• COPD discharge care bundle:

– Improved compliance with ‘best care’ (from 0% baseline - 70%)– reduced length of stay (e.g. by 2.5 days) – costs savings (e.g. estimated at £123,410/year)

• Medicines Management: – ADR identification (e.g. 70% potential ADR)– medication reduction (e.g. 52% meds)– cost avoidance (e.g. estimated net £145,000/yr) – co-designed “My Medication Passport” (paper & app, c.9,000 copies)

• Diabetes Improvement through Peer Led Education (DIMPLE): – Built capacity: 31 “community champions‟, 6 peer educators and 9 peer

mentors – engaged over 9,182 people through 352 events inc BME groups, – Social return on investment estimated at £11 for every £1 invested.

Demonstrated Patient & Public Engagement & Involvement benefits

Include (3 examples):

Conceptual Framework for delivering improvement in healthcare

Act scientifically and

pragmatically

Engage and empower

Embrace Complexity

Support for long term success

Understand and utilise existing knowledgeIterative DevelopmentCapture and produce new knowledgeActive engagementFacilitate dialogueFreedom to act and willingness to learnUnderstand services and processesUnderstand variationIdentify and act on systemic issuesProvide headroom and resourcesPolitical and Strategic AlignmentInvest in continual improvement

Values

Principles

Contribution of QI tools and methods : The CLAHRC NWL approach

    

Resources/ Funding£100k or £50k to develop or ‘roll-out’ projects matched funded by NHS and/or industry partners.

.

Model for Improvement

Three questions and rapid-cycle small tests of change.Measurement for Improvement

A ‘few key weekly measures’ to show progress using run charts and automated SPC charts.

Representative Team (Centre)Clinical lead, project manager, information lead and executive sponsor, plus others including patients.

Process MappingRepresentation of activities

and branching points in a care or data process.

Patient & Public Involvement Patient advisors, digital stories, focus groups…

Action Effect Method

A facilitated approach to represent the ‘theory of

change’ including a patient-focused aim, contributing

factors, and ideas for interventions.

Outcome MeasurementOne or two measures to show impact of the work on outcomes, qualitative or quantitative.

ReviewsTwo-way formative 6 month reviews exploring how teams use and engage with QI tools.

Sustainability Model

NHS III Sustainability Model to identify and address factors that affect sustainability.

Stakeholder MappingTwo-by-two matrix to identify key

stakeholders interest and influence plus management plan.

Act Scientifically & Pragmatically: Utilise existing knowledge

    

.

Model for Improvement

Process Mapping

Action Effect

Method

Act Scientifically & Pragmatically: Iterative Development

    

.

Model for Improvement

Measurement for Improvement

Representative Team (Centre)

Act Scientifically & Pragmatically: Capture & produce new knowledge

.

Model for Improvement Measurement for Improvement

Representative Team (Centre)

Process Mapping

PPE/I

Action Effect

Method

Outcome Measurement

Reviews

Sustainability Model

Stakeholder Mapping

Contribution of QI tools : Act Scientifically & Pragmatically

.

Model for Improvement Measurement for Improvement

Representative Team (Centre)

Process Mapping

PPE/I

Action Effect

Method

Outcome Measurement

Reviews

Sustainability Model

Stakeholder Mapping

Contribution of QI tools : Engage & Empower

.

Model for Improvement Measurement for Improvement

Representative Team (Centre)

Process Mapping

PPE/I

Action Effect

Method

Outcome Measurement

Reviews

Sustainability Model

Stakeholder Mapping

Financial Support

Contribution of QI tools : Embrace Complexity

.

Model for Improvement Measurement for Improvement

Representative Team (Centre)

Process Mapping

PPE/I

Action Effect

Method

Outcome Measurement

Reviews

Sustainability Model

Stakeholder Mapping

Contribution of QI tools : Support Long Term Success

.

Model for Improvement Measurement for Improvement

Representative Team (Centre)

Process Mapping

PPE/I

Action Effect

Method

Outcome Measurement

Reviews

Sustainability Model

Financial Support

QI tools contribution

• All tools make social and technical contributions

• All tools contribute to two or more values

• Most tools contribute to most values• Tools contribute differently to all

values – but exactly how, is still to be explained

• No ‘super-tool’ or subset of ‘super-tools’

QI tools in practice

Model for Improvement Sustainability Model Driver Diagram Measuring for Improvement Process Mapping Stakeholder Engagement PPI Dissemination of Learning Project MedianRound 1

1 1 1 2 3 1 2 2 5 22 3 2 2 3 1 2 5 5 2.53 1 1 2 2 0 2 0 6 1.54 5 1 2 2 1 2 5 6 25 5 1 2 2 6 5 2 6 3.56 3 1 2 6 6 2 2 6 2.5

Median 3.0 1.0 2.0 2.5 1.0 2.0 2.0 6.0

Round 21 5 1 5 3 5 6 5 5 52 5 6 5 3 6 3 6 5 53 5 2 2 4 3 5 3 2 34 3 2 2 2 2 2 2 5 25 1 2 2 2 5 3 2 2 26 5 2 2 3 6 2 2 5 2.57 3 2 2 3 5 3 2 5 38 3 2 2 1 0 2 3 5 29 1 1 2 0 0 1 2 6 1

10 2 2 2 1 0 1 2 1 1.511 2 1 2 1 0 2 3 6 212 5 3 2 0 0 3 2 5 2.513 3 1 2 2 0 2 2 5 214 5 1 2 5 3 3 2 6 315 3 1 5 5 3 3 5 5 416 5 0 2 5 0 2 2 6 217 3 1 2 0 0 1 2 5 1.5

Median 3.0 2.0 2.0 2.0 2.0 2.0 2.0 5.0

Round 31 6 5 6 6 6 5 5 5 5.52 5 0 6 0 6 2 2 5 3.53 1 3 5 1 6 2 5 5 44 3 3 5 1 6 2 6 5 45 1 3 5 0 6 2 5 5 46 4 3 5 5 5 5 2 2 4.57 1 0 1 2 0 2 2 5 1.58 3 1 2 2 3 5 2 0 29 5 0 5 5 6 5 5 5 5

10 5 3 5 5 6 2 2 5 511 6 0 2 0 6 5 2 5 3.512 5 3 6 5 6 4 5 5 513 3 0 5 3 6 6 5 2 414 5 0 5 6 1 6 6 5 515 5 3 5 5 6 6 6 5 516 5 2 6 5 4 2 2 6 4.517 5 3 5 3 6 2 2 5 418 3 3 5 5 6 5 2 3 419 4 0 5 3 6 5 5 2 4.520 4 3 5 5 4 6 5 5 5

Median 4.5 3.0 5.0 4.0 6.0 5.0 5.0 5.0

• The degree of engagement with each of the QI tools and methods varied within and across projects.

• More projects engaged with more methods in each round.

NIHR CLAHRC for Northwest London

Find us at…

W: www.clahrc-northwestlondon.nihr.ac.uk/home

E: clahrc.nwl@imperial.ac.uk

T: @CLAHRC_NWL

Find me at…

W: www.cathyhowe.net

E: c.howe@imperial.ac.uk

T: @cathgreenhalgh