Action on Frailty Learning Event – 28 September 2016

Leading an Improvement Project

Stephen Ramsden

Leading a patient safety improvement project

Some service improvement tools and techniques, this will include:

• Introduction to improvement science• The model for improvement, PDSA and small tests of

change• Measurement for improvement • Key elements of project management• Spread and sustainability

Research Clinical audit Quality Improvement

Performance management

Purpose Generates new knowledgeTests hypotheses

Tells us if we are following good practice

Examines our processes and guides improvement

Judges whether we are meeting required standards

Scope May be generalisable Sample size not necessarily scientifically valid – valid within the organisation

Usually focuses within one institution or process

Institution or part of or system

Measurement Detailed statistical Analysis

Basic statistical analysis

Statistical process control

Bench-marking

Design Scientific framework well controlled

No allocation of patients to different treatment groups

Focuses on three key questions see PDSA

Often determined centrally

Patient involvement

Ethics approval required

No ethics approval usually required

No ethics approval usually required

No ethics approval required

Results used to Generate new knowledge, influence practice

Encourage best clinical practice

Bring about improvement in safety and quality

Ensure compliance with standards

How Can We Foster the Adoption of Successful Change Ideas?

The Traditional Approaches

PolicyManual

MemoDate: February 2012

To: All Staff

From: Management

Starting next Monday, all staff will be

expected to implement the new

procedure we just tested in the 3 West

med/surg unit.

It worked there so in order to save time,

everyone will now start doing the new

procedure like 3 West.

Thank you for your

cooperation.

The model for improvement

The model for improvement is a systematic approach, using specific techniques to improve the quality of healthcare, and patient and staff experience.

The PDSA Cycle for Learning and Improvement

What’s next?

Did it work?

What will happen if we

try something different?

Let’s try it!

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

Improvement Execution

When you combine the 3 questions with the…

PDSA cycle, you get…

…the Model for Improvement

The Sequence of Improvement

Sustaining improvements and Spreading changes to other locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study DoTheory and Prediction

Test under a variety of conditions

Make part of routine operations

Which one is SMART ?I. We will help teams who look after patients to

understand when they should refer patients for a nutritional assessment

II. We will improve nutritionIII. We will aim to increase the number of patients who

get a nutrition screen within 4 hours from 60% to 90%IV. We will increase the number of patients (admitted to

Ward G4) who get a nutritional management plan within 6 hours from 60% to 90% by june 2012

An example……….

Implementing an ‘early warning scorecard at Luton and Dunstable Foundation Trust’

Measurement for improvementMeasurement framework: some principles• Use sampling – make it sufficient• Measures must relate back to your aim(s)• Keep it simple, relevant and able to be incorporated into daily work• Consider process and outcome measures• Plot data over time• Different measures will be appropriate for different audiences – e.g.

ward or Board• Good enough – not perfect!

Three types of Measures

• Outcome measures ie what is the end result that the process/system is achieving

• Process measures ie a measure of the reliability of the process/system

• Balancing measures ie are there any unintended consequences of changes to the outcome and/or process measures . Could be in productivity or mortality or experience etc

Run charts and SPC

• Run charts and control charts turn data into information

• They enable us to understand variation and whether it is special cause or common cause

Getting to reliable – central line bundle

Stop accepting the unacceptable

Types of variationCommon cause • Is inherent in the design of the process• Is due to regular natural or ordinary causes• Affects all the outcomes of a process• Results in a “stable” process that is predictable• Also known as random variation

Types of variation (cont.)

Special cause variation

• Is due to irregular or unnatural causes, not inherent in the design of the process

• Affects some but not necessarily all of the process• Results in an unstable process that is not predictable• Also known as non-random variation

What to look for• Upward trend?

• Downward trend?

• Static line?

• Intervention point?

• Sustained improvement?

• Special cause?

• Normal variation?

Statistical Process Control• Run charts at their simplest• Use upper and lower control limits either side of median (centre) line• Need 15-20 data points • 7 successive points below/above the median or constantly going

up/down is a trend• Points either side of the control limits = look for a special cause• Aim to reduce variation

Every system is perfectly designed to produce the results it achieves !

Conwy & Denbighshire NHS Trust

Critical Care

How do we know care is safe? 22

A self-assessment exercise - measurement

Some questions to ask of your teams:

1. What information do you currently collect?

2. Does it help you to answer the question: how safe is our care?

3. Is your data accurate, comparable and meaningful?

4. Do you need to stop collecting some data?

5. Do you need to start collecting other data?

Small tests of change - tips• Keep tests small• Pick willing volunteers• Choose tests that do not need lots of approval (ask

for forgiveness not permission)• Steal shamelessly/Pinch with pride• Pick easy changes to try• Avoid technical slowdowns• Reflect on every change• Be prepared to change tack or stop your test

Project management

• Charters• Stakeholder mapping• Patient involvement • Driver diagram• Measurement for improvement

Project chartersKey elements include

• Aims• Objectives• What is included & what is not• Benefits• Team• Resources• Sponsor

Stakeholder mapping

Satisfy

Manage

Monitor Inform

Low influence High influence

High power

Low power

Meet their needs Key player

Least important Show consideration

Power/influence of stakeholders

Interest of stakeholders

Stakeholder quadrant

Meet their needs•engage & consult on interest area•try to increase level of interest •aim to move into right hand box

Key player•key players focus efforts on this group•involve in governance/decision making bodies•engage & consult regularly

Show consideration•make use of interest through involvement in low risk areas•keep informed & consult on interest area•potential supporter/ goodwill ambassador

Least important•minimum effort•inform via general communications – newsletters, website, mail shots•aim to move into right hand box]

www.stakeholdermap.com

Patient and family involvement• Surveys• Patient Stories• Patient Experience Trackers• Focus Groups• Complaints/compliments• Shadowing/observing/tracking• 1:1 interviews• Patient groups/volunteers• Patient Experience Committees

Managing Spread and Creating SustainabilityCorinne Thomas

This presenter has nothing to disclose.

Roger’s Adopter Categories

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

‘Traditionalists’

Spreading a change

• Spread is the degree to which learning, best practice or improvement is adopted across an organisation or region by those who would benefit from the change

• Follows implementation on pilot unit• Can occur passively through diffusion or actively

through planned design• Key is to actively move the improvement across the

organisation without causing resistance to change• 1 – 3 - 5

32

The Seven Spreadly Sins(If you do these things, spread efforts will fail!)

Step #1 Start with large pilots

Step #2 Find one person willing to do it all

Step #3 Expect vigilance and hard work to solve the problem

Step #4 If a pilot works then spread the pilot unchanged

Step #5 Require the person and team who drove the pilot to be responsible for system-wide spread

Step #6 Look at process and outcome measures on a quarterly basis

Step #7 Early on expect marked improvement in outcomes without attention to process reliability

Sustainability model

Transforming Health Ltd

0

2

4

6

8

10

12

14

16

Benefits beyond helping patients

Credibility of the evidence

Adaptability of improved process

Effectiveness of the system to monitor

progress

Staff involvement and training to

sustain the processStaff behaviours

toward sustaining the change

Senior leadership engagement

Clinical leadership engagement

Fit with organisational

strategic aims and culture

Infrastructure for sustainability

Sustainability Review SurveyAdminstration Excellence Project

TARGET SCORES

TEAM SCORES

N=10

Sustainability model and guide www.institute.nhs.uk

The gap between the blue shading and the red shading shows the improvement potential for each of the ten factors. Staff involvement, clinical involvement and senior leadership engagement provide the areas for greatest potential improvement.

Some questions to reflect on1. Am I adopting a service improvement approach?2. Have I adequately understood the problem?3. Have I involved the right people?4. Do I have the right leadership involvement?5. Have I understood other perceptions? – emotional, hearts and minds?6. Is my aim clear?7. Is my measurement system clear?8. Am I running tests of change?9. Am I measuring results using SPC on a regular basis and displaying my

results?