whole system quality measures in an integration world dr andrew longmate national clinical lead for...

Whole System Quality Measures in an Integration World

Dr Andrew LongmateNational Clinical Lead for Patient SafetyThe Quality UnitScottish Government

Integration

Don Berwick’s Ethics of Improvement

1. Professionals have a duty to help improve the systems in which they work

2. Leaders have a duty to make 1) logical, feasible and supported

3. No excuses for inaction on 1) and 2) are acceptable4. The duty to improve encompasses safety, effectiveness,

patient centredness, timeliness, efficiency and equity. This requires the continual reduction of waste.

5. Those who educate professionals have a duty to prepare them for this improvement work.

Summary

10. There are learning points from SRFT that could be usefully applied across Scottish health boards to accelerate our journey towards the 20:20 vision. Scottish Government has the opportunity to further accelerate progress towards the 20:20 vision by • clarifying the expectation that Health Boards integrate

the delivery of person centred, safe and effective care at the frontline

• ensuring our national programmes are designed to drive and support integration

• ensuring that Territorial Health Boards are directed to build and apply local infrastructure and capability to drive sustainable quality improvement

Lessons for transformational change1. In order to sustain

transformational change we need to move from a burning platform (fear based urgency) to a burning ambition (shared purpose for a better future)

2. We need to articulate personal reasons for change as well as organisational reasons

3. If the fire (the compelling reason) goes out, all other factors are redundant

@PeterFuda

@helenbevan #Staffschange@PowerNHS@SimonJGuilfoyle Police Inspector and systems thinker

https://twitter.com/SimonJGuilfoyle


@helenbevan #Staffschange@PowerNHS

Purpose

Obfuscation O-

meter

@SimonJGuilfoyle Police Inspector and systems thinker




PolicePlease catch the person

who burgled my house

input

We can only afford another 4.3

burglaries per day for the rest of the month other wise we will miss the reduction target

what the machine

hears

@SimonJGuilfoyle Police Inspector and Systems Thinker


EducationI want my

child to learn

input

Schools should be ranked in league

tables according to the proportion of

students who attain results at

Grades A - C

what the machine

hears



HealthcareHelp me get

better

input

A 95th percentile of A and E patients

must be admitted, discharged or

transferred within 4 hours of arrival in the department

what the machine

hears


Drivers of extrinsic motivation

create focus & momentum for delivery

Intrinsic motivators •connecting to shared purpose•engaging, mobilising and calling to action•motivational leadership

build energy and creativity

•System drivers & incentives•Payment by results•Performance management•Measurement for accountability

Internal motivators •connecting to shared purpose•engaging, mobilising and calling to action•motivational leadership

build energy and creativity

Drivers of extrinsicmotivation

•System drivers & incentives•Performance management•Measurement for accountability

create & focus momentum for delivery


Avoiding “de facto” purpose• What leaders pay attention to matters to staff, and consequently

staff pay attention to that too• Shared purpose can easily be displaced by a “de facto” purpose:

hitting a target reducing costs reducing length of stay eliminating waste completing activities within a timescale complying with an inspection regime

• If purpose isn’t explicit and shared, then it is very easy for something else to become a de facto purpose in the minds of the workforce

Source: Delivering Public Services That Work: The Vanguard Method in the Public Sector


“If people give to a cause, they expect a relationship, not a transaction”

Nilofer Merchant

“To return 20,000 well and healthy

days to our community”

The “Quality Journey”

Compliance

Comparison

Culture

▪To meet all required targets

▪To be better than others, locally or nationally

▪To be the best we can possibly be

▪From outside

–Imposed

▪From outside

–Top-down

▪From inside

–Internal, personal

▪Episodic ▪Episodic ▪Ongoing

How we define ‘good’

Source of motivation to deliver

Duration

• Development of goals is a dialogue, top down, bottom up

• Engagement of health care professionals, especially doctors

• Integrate measurement into daily work, use it to learn and guide change at all levels

• Goals and measures used at all levels throughout the organisation

• Robust and timely data and IT systems• A culture of learning, open enquiry, non blame

World Leading Organisations I

•Dedicated organisational structure for QI •All work-streams are assessed against the 6 domains of quality•Quality leaders at Board and operational levels•Individual responsible for Q and S•Standard Improvement methodology adapted for local conditions

World Leading Organisations II

Jennifer Dixon: 6 principles for taking QI to scale in NHS

1. Start bottom-up (microsystems) and unleash front line improvement as natural part of daily work and professionalism2. Focus also on ‘mesosystem’:

- Organisational leadership to understand the need for 1 and actively enable it; - Pathways: take a quality measurement/improvement ‘cut’ on provision across whole systems / organisational silos reflecting patient journeys and improve

3. Build skills systematically for microsystem and mesosystem levels [involves skills for front-line and executive tier and trainers/coaches for each level]4. Evaluation/Applied Health Research: “Evaluation needs to stop letting QI down” – QI methods aren’t acceptable to traditionalists; need to build cachet around QI research/evaluation and methods it (& do this rigorously) 5. Build networks across whole country: provide guidance, “safety in numbers”, allow experimentation and (vitally) “failure linked to learning”6. Macrosystem (policy) context must be less hostile (eg payment systems, operating framework, regulatory regime). Summed up in shift from policy focusing on organisations to systems and pathways).

How can we support a piece of improvement work around X and Y…that

• Builds intrinsic motivation, relationships and commitment to our common purpose

• Uses and generates improvement capability and capacity at Boards

• Encourages collaboration• Supports integration • Helps Scotland take those next steps on

our Quality Journey

@AndyLongmate

[email protected]

whole system quality measures in an integration world dr andrew longmate national clinical lead for...

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