nurses making a difference through quality...

Nurses making a difference through Quality Improvement

WithProfessor Jonathan WarrenDeputy CEO and Chief NursedEast London Foundation Trust

Plan for today

• Introductions

• What do we mean by quality?

• What type of leadership do we need?

• Intro to QI methodology

• QI stories

• leading change through QI

A B C D E

1Is allergic to

catsHas a dog

Cycles to work

Dislikes mushrooms

Enjoys shopping at

Westfield

2Can speak another language

Lives in Bedford

Would rate pizza in theirtop 10 meals

Takes the tube to

workOwns a car

3

Would rate Star Wars in their top 10 films of all

time

Is afraid of spiders

Is the tallest in their family

Is a football fan

Lives in Luton

4Has already done some QI training

Has a catWasn’t born

in the UKWorks on a

wardCan curl

their tongue

5Has been on the London

Eye

Cycles to work

Has been to a football

match

Is afraid of heights

Has already been part of a QI project

BINGO!

Instructions

You are aiming to be the first person to complete a full line on the bingo sheet!

Complete lines by finding people who can meet the criteria in the boxes.

Lines can be horizontal, vertical or diagonal.

To win, you must find different people for each box.

At the end of the challenge you must also be able to name the people who meet the criteria.

There will be a prize!

Take a moment

What do we mean by “quality”?


Video - Cleveland Healthcarehttps://www.youtube.com/watch?v=cDDWvj_q-o8

https://www.youtube.com/watch?v=cDDWvj_q-o8

Clinical effectiveness

SafetyPatient

experience

Darzi, High Quality Care for All, 2008Institute of Medicine, Crossing the Quality Chasm: A New

Health System for the 21st Century, 2001


Take a moment

Why is it hard to deliver the best quality healthcare all the time?

Simple? Complex?

How about healthcare?

QI in a nutshell

Why are we so

committed to QI?

Research & innovation

Quality improvement

Assurance, control &

performance management

QualityBetter

Reject defectives

Requirement,Specification or Threshold

No action taken here

Worse

The Quality Assurance Approach

Performing well?

Research & innovation

Quality improvement

Assurance, control &

performance management

The culture we want to nurture

A listening and learning organisation

Empowering staff to drive improvement

Increasing transparency and openness

Re-balancing quality control, assurance and

improvement

Patients, carers and families at the heart of all

we do

The Tennis Ball Game

Break out Exercise

Before we start…

• How many people are sitting at your table?

5, 6, 7, 8 or 9

• Assign a time keeper

• Assign a number to each of the other

people at your table, starting with the

number 1 and continuing until you run out

of people

Break out Exercise

Your current process involves tossing a tennis ball

from person to person, following the sequence

provided on the next slide

Practise your process one time

Time keeper - please time how long the team takes

to complete the process (in seconds). Create a

line chart of time taken for every time you run the

sequence

6 people

7 people

8 people

9 people

1

2

3

4

5

6

1

1

2

3

4

6

7

5

1

1

5

3

4

7

8

2

6

1

1

2

3

5

7

9

6

4

8

1

5 people

1

1

2

3

4

5

Here we go…Practice run

Break out Exercise

Team Aim: To reduce the time taken for every person to

touch the ball

Come up with change ideas and try them out

Rules:

• The initial sequence as provided must be adhered to

• You may only test one change idea at a time

6 people

7 people

8 people

9 people

1

2

3

4

5

6

1

1

2

3

4

6

7

5

1

1

5

3

4

7

8

2

6

1

1

2

3

5

7

9

6

4

8

1

5 people

1

1

2

3

4

5

How did you get on ?

QI in a nutshell

IHI Model for Improvement


AIM

Break out Exercise


touch the ball by the end of this session


Rules:



Developing a project aim

Break out Exercise

“To reduce patient falls on Ivory ward by 15%

by December 2017”

“75% of people accepted into the South Beds

Memory Assessment Service pathway should

receive a diagnosis within 12 weeks by April

2017”


MEASURES

Break out Exercise

Your current process involves tossing a tennis ball

from person to person, following the sequence

provided on the next slide

Practise your process one time

Time keeper - please time how long the team takes

to complete the process (in seconds). Create a

line chart of time taken for every time you run the

sequence

Where would you choose to go for your Coronary Artery Bypass

Graft (CABG) surgery?

Measurement

Hospital Average Percent Mortality

Average CABG Cost

A 3.48% £17,000

B 3.48% £13,000

C 3.48% £14,500

Hospital A: % Monthly CABG Mortality

Percent Mortality

# M

on

ths F

allin

g

in T

his

Cate

go

ry

0

1

2

3

4

5

6

7

Hospital B: % Monthly CABG Mortality

Percent Mortality

# M

on

ths F

allin

g

in T

his

Cate

go

ry

0

1

2

3

4

5

6

7

Hospital C: % Monthly CABG Mortality

%

Mortality

# M

on

ths F

allin

g

in T

his

Cate

go

ry

0

1

2

3

4

5

6

7

Average: 3.48%

Average: 3.48%

Average: 3.48%

Hospital A

Hospital C

Hospital B

Data in a histogram

Would you still choose the same

hospital?

Hospital A: Percent CABG Mortality

Sequential Months

Pe

rce

nt

1 2 3 4 5 6 7 8 9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

1

2

3

4

5

6

Mean

Hospital B: Percent CABG Mortality

Sequential Months

Pe

rce

nt

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

2

3

4

5

6 UCL

Mean

Hospital C: Percent CABG Mortality

Sequential Months

Pe

rce

nt

1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

0

1

2

3

4

5

6

7

Mean

Average cost = $17,000



Data over time

Would you still choose the same

hospital?


CHANGES

Break out Exercise


touch the ball


Rules:



Patients & carers

1. Patient choice and empowerment

2. Communication between and with SUs

3. Responsiveness-patients having to wait

4. Community meetings , newsletters

Staff

1. Communication between staff

2. Attitude (flexibility, openness, respect)

3. Training

4. MDT meetings to plan for violence

5. Flattened hierarchy

Environment and

infrastructure

1. Ward env. (homeliness, comfort, food )

2. Patient property

3. Ward rounds

Treatment

1. Clinical prediction tools

2. Prescribing

3. Complementary therapies

AIM PRIMARY DRIVERS SECONDARY DRIVERS

Tower Hamlets Violence Reduction Collaborative

CHANGE IDEAS

Safety huddles

Intentional rounding

Daily reviews

Broset Violence Checklist

Safety cross

Patient property bins

Ward activities

Mindfulness

S17 Leave

Proactive PRN

Safety discussion in community meetings

To reduce physical violence

at THCFMH by 30% by end of

2015


TEST

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

What will

happen if we

try something

different?

Let’s try it!Did it

work?

What’s

next?

The PDSA Cycle for Learning and Improvement

Failure?

It took multiple attempts to perfect the formula to stop corrosion by displacing moisture.

In 1953, on the 40th attempt, chemist Norm Larsen finally got it right:

Failure?

Water Displacement 40th attempt

Leadership for improvement

#QIwave3

What is the context within which we lead?

What type of leadership behaviours are best suited for this context?

“Culture is a set of shared, taken-for-granted implicit assumptions that members of an organisation hold and that determines how they perceive, think about and react to things.”

Edgar Schein (1992)

Organisational culture

Every interaction reveals and shapes the

culture

Reflects what an organisation

values

Co-created by all in the

organisation

Dynamic

Most important determinant is

current and future leadership

Leaders

Power to reward or

punish

Control information & resources

Make choices about

structures

Shape the work lives of others

Collective leadership means the distribution and allocation of leadership power to wherever expertise, capability and motivation sit within organisations

The purposeful, visible distribution of leadership responsibility onto the shoulders of every person in the organisation

Leadership for cultures of high quality care

1. Prioritising an inspirational vision and strategic narrative – focused on quality

2. Clear aligned goals and objectives from Board to front line

3. Supportive people management

4. High levels of staff engagement

5. Continuous learning and quality improvement the responsibility of all

6. High levels of genuine team working and cooperation across boundaries

The top priority

Communicate an inspiring, forward-looking and ambitious vision focused on offering high-quality, compassionate care

Reiterate the message at every level that this is the core purpose of all staff

1. Vision

Staff often report being overwhelmed by workload and unclear about priorities

Vision and mission statements provide a directional path. This needs to be translated into clear, aligned, agreed and challenging objectives at all levels of the organisation

2. Clear aligned goals at every level

If we want staff to treat patients with respect, care and compassion, all leaders and staff must treat their colleagues with respect, care and compassion

Staff views of their leaders are strongly related to patients’ perceptions of quality of care

3. People management

4. Staff engagement

Staff engagement = an experience of work that is involving, at times exciting, meaningful, energising, affirming, stretching and connecting

Characterised by strong identification with the organisation, a drive to be involved in decision-making and innovation to improve the delivery of care

Staff engagement trumps all other measures as the best overall predictor of patient and organisational outcomes

4. Staff engagement

Leaders can create the conditions for high staff engagement by:

• Promoting a positive climate

• Recognising staff contributions

• Providing information

• Giving helpful feedback

• Supporting staff innovation

• Promoting fairness and transparency

• Developing trusting relationships

A compelling strategic narrative

Inclusive leadership and management

styles

Putting staff in charge of service

changeValues and integrity

Successful Trusts develop a clear narrative on their purpose and aims

Salford Royal aimed to be the safest hospital in England

Successful Trusts have invested in retraining staff to adopt inclusive management styles

Oxleas has introduced a substantial programme to retrain middle managers in facilitative leadership

Notts Healthcare develops leadership around strategy and values

Successful Trusts give staff responsibility for leading service change

Wrightington, Wigan and Leigh works with Unipart to support staff-led change

Salford’s quality directorate supports teams of frontline staff in testing improvements

Staff survey evidence highlights importance of values and trust in senior leadership

Perceptions of unfairness are our best predictor of intention to leave

In particular, fairness of procedures, bullying and discrimination

Stable senior leadership

It is striking that many of the Trusts with highest levels of engagement have had the same senior leaders for over a decade: CEO of Oxleas in post in 2002, CEO of Salford in post since 2002, CEO of Frimley Park in post

since 1998, in comparison with an average tenure of less than 2 years

5. Continual learning and QI

Sustaining cultures of high quality care involves all staff focusing on continual learning and improvement of services

Learning organizations facilitate the learning of all

staff and the organisation to continuously improve

high quality, compassionate care

Where there is a culture of collective leadership, all staff members are likely to intervene to solve problems, to ensure quality of care and to promote responsible, safe innovation

5. Continual learning and QI

Leaders can support this by:

• Ensuring teams at all levels collectively take time out to review and improve their performance

• Mastering quality and patient safety sciences, and ensuring this is a priority for all

• Promoting high levels of dialogue, debate and discussion across the organisation to achieve shared understanding about quality problems and solutions

6. Genuine team working

• Clear, shared team objectives

• Role interdependence and role clarity

• Meeting regularly to review and improve performance

Other foundations for success:Team member interdependence Team focus on quality

Team autonomy Team innovation

Members’ role clarity Team reflexivity

Team leader clarity Lack of team conflict

Team communication Inter-team working

To what extent and how effectively do leaders at every level:

1. Promote engagement, participation and involvement as their core leadership strategy?

2. Promote appropriate staff autonomy and accountability?

3. Ensure staff ‘voices’ are encouraged, heard and acted on?

4. Encourage staff to be responsibly proactive and innovative?

5. Avoid domination, command and control except in crisis?

6. Take action to address systems problems

7. Deal effectively with intimidating behaviour and poor performance?

8. Model compassion in dealing with patients and staff?

9. Build effective teams

Leadership V Management

• https://www.youtube.com/watch?v=u6XAPnuFjJc&index=13&list=PL39BF9545D740ECFF

https://www.youtube.com/watch?v=u6XAPnuFjJc&index=13&list=PL39BF9545D740ECFF

@ELFT_QIqi.elft.nhs.uk [email protected]

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