wednesday 9th december 2015 & wednesday 9th march 2016
DESCRIPTION
Programme this morning What is Quality Care? Problem Hunting 360 Patient Safety Appraisal Process Mapping What to change? Driver Diagrams How to change things? PDSA cycle Measurement for change QI ResourcesTRANSCRIPT
‘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 [email protected]• Dr Susan Hadley. PD
[email protected]• Dr Christine Johnson.
[email protected]• Dr Graham Todd [email protected]• Dr David Young [email protected]• Dr Helen Tallantyre
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