Improving Safety and Quality of Patient Care- mastering the how

Leadership StylesLeadership for Safer Care

Front line LearningMeasurement for Safety Improvement

Context for Our Leadership

‘No matter what leaders set out to do—whether it’s creating strategy or mobilizing teams to action—

their success depends on how they do it. Even if they get everything else just right, if leaders fail in this

primal task of driving emotions in the right direction, nothing they do will work as well as it could or

should’ Daniel Goleman

Exercise 1Reviewing Styles You Have Used This

Week

• In what situation? One sentence

• Was your choice conscious ? Yes or No

• Impact at the time?

• Impact subsequently?

• Impact evidence predicted ?

Two actual realities in communities

• I take action on my beliefs

Action

• I adopt beliefs about the world

Beliefs

• I draw conclusions Conclusions

• I make assumptions based on the meaning I added

Assumptions

• I add meanings Meanings

• I select data from what I observeSelect

•Observable data and experiences Observe

ARGYRIS- LADDER OF INFERENCE ROGERS -INNOVATION ADOPTION CURVE

Exercise 2.Rethinking Behaviours

Listen = Silent

• Who are the early majority?-

How are they encouraged?

• What questions make it clear that safety is the priority?

When and how do I ask them

A classic approach to developing measures8

S + P = O

Structure + Process = Outcomes

Source: Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches To Its Assessment. Ann Arbor,

MI, Health Administration Press, 1980.

Dr. Avedis Donabedian(1919-2000)

Systems deliver care as well as people& We need to Work on and in them

Vincent 2013

Exercise 3.Rethinking Messages and Meetings

• What data could you use to develop a safety focused agenda?

• Structures and Processes for safer outcomes

S + P = O

Tools 1.Enabling Improvement to Follow on

from Audit Select Standard

or

Re-audit position

Select Sample

Comparing reality with

standard

Identify the gaps

Apply Improvement Methodology

aim

1er driver

2er driver

2er driver

1er driver 2er driver

Conceptual Framework

Current Situation Resistant Indifferent Ready

Low

Confidence that

current change

idea will lead to

Improvement

Cost of

failure

large

Very Small

Scale Test

Very Small

Scale Test

Very Small

Scale Test

Cost of

failure

small

Very Small

Scale Test

Very Small

Scale Test Small Scale

Test

High

Confidence that

current change

idea will lead to

Improvement

Cost of

failure

large

Very Small

Scale Test Small Scale

Test

Large Scale

Test

Cost of

failure

smallSmall Scale

Test

Large Scale

TestImplement

Tools 2.Think About Which Conditions Prevail

© 2009 R C Lloyd and IHI

Tools 3.Three Faces of Performance Measurement

Aspect Improvement Accountability Research

Aim Improvement of care Comparison, choice,

reassurance, spur for

change

New knowledge

Methods:

• Test Observability

Test 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 of

Hypothesis

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

13

“What is the variation in one system over time?”Walter A. Shewhart - early 1920’s, Bell Laboratories

time

UCL

Every process displays variation:• Controlled variation

stable, consistent pattern of variation“chance”, constant causes

• Special cause variation“assignable” pattern changes over time

LCL

Static ViewStatic V

iew

Dynamic View

Percent of A&E patients Seen by a Physician within 10 min

Did we improve?

What will happen next?

Should we do something?

Source: R. Lloyd

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

10

/3/2

00

7

10

/17

/20

07

10

/31

/20

07

11

/14

/20

07

11

/28

/20

07

12

/12

/20

07

12

/26

/20

07

1/9

/20

08

1/2

3/2

00

8

2/6

/20

08

2/2

0/2

00

8

3/5

/20

08

3/1

9/2

00

8

Change made here

Source: R. Lloyd

Did we improve?

What will happen next?

Should we do something?

Percent of A&E patients Seen by a Physician within 10 min

70

35

0

10

20

30

40

50

60

70

80

Avg

Before

Change

Avg After

Change

Cycle

Tim

e (

min

.)

Aggregated Cycle time results for units 1, 2 and 3

010

20304050

607080

90100

dat

e

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

Dec

Change

MadeCyc

le T

ime

(min

.)

010

20304050

607080

90100

date Jan

Feb

Mar Apr

May Jun

Jul

Aug

Sep

Oct

Nov Dec

Change

Made

Cycl

e Ti

me

(min

.)

010

20304050

607080

90100

date

Jan

Feb

Mar

Ap

r

May

Jun

Jul

Au

g

Sep

Oct

No

v

Dec

Change

Made

Cycl

e T

ime (

min

.)

Unit 1

Unit 3

Unit 2

Facilities, support, encouragement & leadership