HIGH FIVE - IHI Home Pageapp.ihi.org/FacultyDocuments/Events/Event-2760/... · 2016-12-04 · HIGH...

HIGH FIVEPeople at the Centre of Improvement

The Five Essentials of Quality Improvement Dr Pat OConnor

Scottish Ambulance Service Dr Peter Lachman

CEO, The International Society for Quality in Health Care

Key outcomes of today

• Have fun • Discuss are people at the centre of your

healthcare systems…. patients and families and healthcare teams

• Sharing and learning build on what we have • Your box to go (take away tools) share and

exchange • Make a plan to at least try one new thing you

learned

Key content of The High Five

Improving Access Improving Care Improving Outcomes

• Is everything ....islands of excellence •Where are the bright spots and how do we build on these? • Strong and loose ties

Context

•Understanding self and others-Team dynamic •Mindfulness, emotional intelligence: FEELINGS matter at work •Make the right thing easy to try, easy to do and easy to try!

Making Change Happen

• Improvement science e.g. Model for improvement, lean •Triple aim (patient experience, ROI, improved clinical outcomes) •Community asset management

Methods tools and techniques

•Measurement MATTERS•Generate light not heat! Measures for improvement •Dash board of measures- Run and control charts•Info graphics

Measuring Results

•Deep and broad understanding of what it takes to sustain change... reliability and resilience in care delivery ..Sensitive to operations (Safety II )

•Acknowledge and monitor spread• Celebrate Success

Holding the Gains

O’Connor 2015, Unpublished

http://en.wikipedia.org/wiki/File:Ambulancelogo.jpg


People at the Center

Are people at the center of your service? ….Staff Patients and carers

Lets hear some examples: Chat to your neighbour share the ways you think people are at the centre of your care system

Changing from

What’s the matter? To

What matters to you?

• Asking what matters• Listening to what matters• Doing what matters

We challenge you to ask the next patient you care for, ‘what matters to you?’

What matters to you video

https://www.youtube.com/watch?v=T-SkAb52f58

https://www.youtube.com/watch?v=T-SkAb52f58

Jennifer Rogers on what matters to you

Ask patients and colleagues

Finish the sentence

“…Today would have been better if….”

The 4 principles of person centred care

http://www.health.org.uk/public/cms/75/76/313/4772/Measuring%20what%20really%20matters.pdf?realName=GuxZKx.pdf

Dignity respect compassion

Coordinated

Personalised

Enabling

http://www.health.org.uk/public/cms/75/76/313/4772/Measuring%20what%20really%20matters.pdf?realName=GuxZKx.pdf

What makes the best care experience?

What makes the best service?

Discuss with your neighbor what is the best service you have every had outside healthcare and why?

People at the centre

Good example you heard Something you need help with

1 Context

• Is everything ....islands of excellence • Where are the bright spots and how do

we build on these? • Strong and loose ties

Professor Paul Bate

Islands of Excellence

• Islands of Excellence in a Sea of Mediocrity• We are good at everything …….just not

everywhere • Good examples of improvement …how are

they mapped how do you know? • Reaching out and encouraging others to reach

in

Looking for the bright spots

Dan Heath

https://www.youtube.com/watch?v=zbLNOS7MxFc



Strong and loose tiesHelen Bevan

• In health and care, most change happens through “strong ties”.

• We are influenced to change by “people like us”, with the same background, interests and experiences as us; change is spread peer-to-peer.

• Yet the best opportunities for breakthrough, radical change comes when we also operate through “weak ties”, connecting with people who aren’t in our usual peer group who bring fresh ideas, influences and perspectives.

http://theedge.nhsiq.nhs.uk/the-strength-of-weak-ties/

http://theedge.nhsiq.nhs.uk/the-strength-of-weak-ties/

Context considerations for change

Context

For quality improvement to flourish it must be carefully cultivated in a rich soil bed (a receptive

organisation), given constant attention (sustained leadership), assured of appropriate

amounts

Bate 2014

8 factors of receptive contexts for change

Context within which you work

In your organization what is helping you to improve and what is holding you back?

2 Making Change Happen

• Understanding self and others-• Team dynamic • Mindfulness• Emotional intelligence• FEELINGS matter at work • Make the right thing easy to

try, easy to do and easy to try!

AIM

Is there an agreed aim that is understood by every one in the system?

CORRECT CHANGES

Are we using our full knowledge to identify the right changes and prioritising those likely to have the biggest impact on our AIM?

CLEAR CHANGE METHOD

Does everyone know and understand the method(S) we will use to improve?

MEASUREMENT

Can we measure and report progress on our improvement aim?

CAPACITY AND

CAPABILITY Are people and other resources being deployed and developed in the best way to enable improvement?

SCALE UP AND SPREAD

Have we set out our plans to test implement and scale up, innovate and share new learning to spread improvement everywhere its needed?

SIX Fundamental questions we must ask of all changes we are trying to make

The Science of Influence

https://www.youtube.com/watch?v=cFdCzN7RYbw

https://www.youtube.com/watch?v=cFdCzN7RYbw

Where are you trying to change practice ?

• When you see results somewhere else and try it in your area is it working?

• Again share at your table – when you have been successful in

improvement what did you do?

InfluenceTo achieving balance and demonstrating understanding of the

needs that underpin the position of the other

So you feel…Tell me more…

I understand how you feel…

What can we/you do…?

27

The Five Conflict-Handling ModesA

sser

tiven

ess

Cooperativeness

Asse

rtive

Una

sser

tive

Uncooperative Cooperative

Competing Collaborating

Avoiding Accommodating

Compromising

The Urban Monk

https://theurbanmonk.com/resources/ch5/

https://theurbanmonk.com/resources/ch5/

Conflict

• Competing – assertive and uncooperative, a power oriented mode. Self-interest.

• Collaborating – both assertive and cooperative. Work with others.

• Compromising – intermediate in both assertiveness and cooperativeness. Finding mutually agreeable solutions.

• Avoiding is unassertive and uncooperative. Steer clear of the issue!

• Accommodating – unassertive and cooperative. Neglects own interests to satisfy the other.

Habits of Improvers

http://www.health.org.uk/publication/habits-improver

The Health Foundation 2015

http://www.health.org.uk/publication/habits-improver

Making change happen

What tools do you use share with your neighbour

Making change happen…or not

• Singular piecemeal efforts will not work • Education alone will not change behaviour• Measurement is not change• Exhortation and incentivisation alone work only if

you believe that poor motivation is the root cause of the problem

If you want different results, change the system !

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

Roger’s Adopter Categories

Change the world

Create the conditions

Make the improvement

Macro system Set Vision, aim and context.

Meso system Capability, Challenge. Measurement Culture

Micro system Implementation, measurement and improvement

Three step Improvement Challenge

Adapted from IHI

Kotter’s Change theory

Kotter 1990

Methods tools and techniques

Break 2.30pm -3.00pm

3 Methods, tools and techniques

• Improvement science• Model for improvement,• Lean process mapping • Triple aim • Community asset

management

Reference Donabedian

Structure Process Outcome

Quality Improvement in healthcare

https://www.youtube.com/watch?v=jq52ZjMzqyI

https://www.youtube.com/watch?v=jq52ZjMzqyI

Deming

•Beliefs•Assumptions •Motivation • Interaction

• Learning from theory and experience

•Prediction•MFI•PDSA

•To be expected•Common and special

cause•Tampering •Capability

• Interaction•Optimisation• Sub systems•Micro system theory

Systems Variation

Psychology Theory of

knowledge

Profound or Improvement Knowledge

Knowledge for Improvement

Profound Knowledge

Subject Matter Knowledge

ImprovementLearn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement.

By what method

Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

http://www.ihi.org/resources/Pages/Publications/ImprovementGuidePracticalApproachEnhancingOrganizationalPerformance.aspx

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?

Did it work?

What’s next?

The PDSA Cycle

Do It !!!

The test was planned (including a plan for collecting data).The plan was attempted (do the plan). (Make a prediction)Time was set aside to analyze the data and studythe results. Action was rationally based on what was learned.

Source: Improvement Guide pp..60-61

TO BE CONSIDERED A PDSA CYCLE…

IHI Triple Aim

Better experience

Better health

Great Staff experience

Lower cost

The Quadruple Aim

Reference IHI

Focus on your assets

Needs Assets• Focus on deficiencies • Focus on strengths

• Result in fragmentation of responses to local deficiencies

• Build relationships among people, groups, and organizations

• Make people consumers of services; builds dependence on services

• Identify ways that people and organizations give of their talents and resources

• Give residents little voice in deciding how to address local concerns

• Empower people to be an integral part of the solution to community problems and issues

Focus on what you have

Create the beginnings of an asset map At your table record 3 things that are contributing to improvement share with your neighbor

Values to Action

Inertia

Apathy

Fear

Self-doubt

Isolation

Urgency

Anger

Hope

You can make a difference

Inclusion

Action inhibitors Action motivators

Ove

rcom

e

Us as change leaders




Measuring Results

• Measurement MATTERS• Generate light not heat! • Measures for improvement • Dash board of measures• Run and control charts• Info graphics

Measuring Results

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Goal

Work-up done on floor

Bed ahead

Individual responsiblefor bed control

Quick-look x-rays

2/16/98 3/16 4/13 5/11 6/8

Week

Minimum Standard for Reporting Data in a QI Project: Annotated Time Series

15 Diabetes Clinic teams

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Scales for Small Multiple Graphs

27 3034

45 45 46 47 4743

47 48 48 4843 42 44

4 4 510 12 11 12 13 13 12 12 12 13 13 13 14

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% of Patients with HbA1c <7- Aggregate of Diabetes Teams

Collaborative Data Analysis –Small Multiples to Support Aggregate Displays

Out of Hospital Cardiac Arrest Programme 10% increase in ROSC across Scotland Co-Responding test with Scottish Fire & Rescue Service evaluation by Xmas ’16 Secured Health Foundation investment for remote and rural trialWildcat programme commenced 138 CFRS (1500+ volunteers) Co-hosted first European Resuscitation Academy to be held in the UK (June ‘16) Pilot Co-responding with Police Scotland in Grampian for cardiac arrests

Clinical Services Transformation

0%

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20%

30%

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80%

Return of Spontaneous Circulation for VF/VT patients

VF/VT ROSC Control Line (Pbar) UCL LCL Upper 3rd Lower 3rd Aim

61

Hear and TreatRecruitment of additional clinical advisors and supervisors to establish clinical services hubGP support to enhance triage and response for GP urgent requests

0.0%

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Apr-16

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Hear & Treat Trajectory

Forecast Monthly % Hear & Treat Trajectory Hear & Treat Target


Patient Pathways Active and Independent Living Improvement Programme (AILIP) established, SAS key member Collaborative event on 25th November - 24 IJBs have joined collaborative to date All divisions have Senior Divisional lead and a core group of local leads to work with partners on developing, establishing and improving local pathways (priorities: falls, respiratory, mental health). Falls & Frailty page on the new ePR due for release next year Enabling more robust data collection for falls and frailty patients Potential to move to electronic referrals from the Service to Falls Teams


60.0%

62.0%

64.0%

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80.0%

Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17

Emergency Conveyence Rates

Emergency Conveyance %

Frail Elderly Conveyance %

Median: 73.5%

Median: 64.8%

Measurement for Improvement

3 types of measures– outcome, process and balancing

Pragmatic Actions:• Tests Observable• Bias Stabilised• Just Enough Data• Adapts with Change• Rapid Cycle Change Sequential Tests• Run or Control Charts

The Three Faces of Performance Measurement

Aspect Improvement Accountability ResearchAim Improvement of care Comparison, choice,

reassurance, spur for change

New knowledge

Methods:• Test Observability

Test is observable No test, evaluate current performance

Test blinded or controlled

• 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 ofHypothesis

Hypothesis flexible, changes as learning takes

place

No hypothesis Fixed hypothesis

• Testing Strategy Sequential tests No tests One large test

• Determining if aChange is anImprovement

Run charts or Shewhart control charts

No change focus Hypothesis, statistical tests (t-test, F-test, chi

square), p-values

• Confidentiality ofthe Data

Data used only by those involved with improvement

Data available for public consumption and review

Research subjects’identities protected

“

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.

http://www.qihub.scot.nhs.uk/improvement-journey/introduce/how-do-we-refine-the-measurement-plan.aspx

BELIEF

Low degree of belief

that change idea will lead

to improvement

High degree of belief

that change idea will lead

to improvement

Current commitment within organisationNo

commitmentSome

commitmentStrong

commitment

COST OF FAILURE

Cost of failure large

Cost of failure small

Cost of failure large

Cost of failure small

Very small scale test


Small scale test




Small scale test

Large scale testSmall scale test


ImplementLarge scale test

Testing and Implementing a Change Idea

Example of 3 Step Design in Implementing the Ventilator Bundle

Integrate daily goals with MDR to identify defects

EducationBaseline

Feedback on compliance

check built into 1 hour scheduled vent checks

Example of using 80% and 95% change concepts to initially reach a reliability of 80% then additionally using a robust change concept (redundancy) to reach 95% reliability in the 4 elements of the ventilator bundle

(Baptist Memorial, Memphis)

Teaching andawareness

5 Holding the Gains

• Deep and broad understanding of what it takes to sustain change... reliability and resilience in care delivery ..

• Sensitive to operations (Safety II )

• Acknowledge and monitor spread

• Celebrate Success

Starting Labels of Reliability

• Chaotic process: Failure in greater than 20% of opportunities

• 80 or 90 % : 1 or 2 failures out of 10 opportunities(lacks consistent clear understanding of the process, 5 front line process users

can not easily articulate the process)

• 95% or better : 5 failures or less out of 100 opportunities(has some variation but 5 front line users can easily articulate the process)

(These are IHI definitions and are not meant to be the true mathematical equivalent)

Car service

Brakes Tyres Oil Filters

Car 1 Yes No Yes YesCar 2 Yes Yes Yes YesCar 3 Yes Yes No YesCar 4 Yes Yes Yes YesCar 5 Yes Yes Yes Yes

Car service

• Brakes 100%• Tyres 80%• Oil 80%• Filters 100%• Overall 60%

4 times out of 10 you don’t get a proper service

Aim for high reliability

•Regarding small errors as a symptom that something is wrong

Preoccupation with failure

•Paying attention to what’s happening on the front-line

Sensitivity to operations

•Encouraging diversity in experience, perspective, and opinionReluctance to

simplify

•Capabilities to detect, contain, and bounce-back from events

Commitment to resilience

•Pushing decision making down to the front line

Deference to expertise

Anticipate

Contain

Move from safety 1 to safety 2

Things that

Are difficult but go right

Things that go wrong

Early completion

Excellent innovation

Positivesurprises

Unwanted Outcome Planned Great outcome

Hollnagel E., Wears R.L. and Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net

• If not You………………………………….. Who

Making it stick

• What have you changed in practice that has been sustained?

• How do you think that happened? • What are the key characteristics?• Discuss with your neighbor

Holding the gains

• Making it stick• What have you changed in practice

that has been sustained? • How do you think that happened? • What are the key characteristics?• Discuss with your neighbor

Profound Knowledge

Subject Matter Knowledge

What Prevents ActionLet’s Change the ConversationEveryone knows what they don't want Let’s start to focus and describe what we want What would be happening if things were going

great and what behaviours get results? Need to be specific when solving people

problemsCreate opportunities for teams to describe and

develop their own solutions




Be curious always

• IQ – Intelligence Quotient–processing complex data sets and having the mental capacity to problem solve at speed

• EQ – Emotional Quotient–the ability to perceive, control and explain emotions; risk-taking, creating resilience and empathy

• CQ – Curiosity Quotient–inquisitive, open to new experiences, finding novelty exciting

Chamorro-Premuzic T. “Curiosity Is as Important as Intelligence.” Harvard Business Review. Aug 27, 2014.

Share and Exchange

People at the center

Our contacts [email protected] @sparklescot

[email protected] @peterlachman

mailto:[email protected]

mailto:[email protected]

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