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NACAP Regional QI WorkshopsLiverpool – 30 May 2019

Welcome, context, plan for the dayProfessor Mike Roberts

Speakers, facilitators, NACAP teamMike Roberts James Calvert

Dennis Wat

Sally SinghBinita Kane

Ian Sinha

John Hurst

Becky Dubben

Agnese Lazzari

Gabriella Massa

Neena Garnavos

Liam Shanahan

Viki McMillan

Eloya Imoedemhe

Housekeeping

• Feedback forms

• Twitter @NACAPAudit, and event hashtag is #NACAPAuditQI

Toilets Lunch and refreshments

No planned fire alarms

Emergency exits

Context• The following audits are collecting

data continuously: • COPD (since Feb 17) = 168,000 cases

entered.• Adult asthma (since Nov 18) =

12,000 cases entered.• Pulmonary rehabilitation = 1,600

cases entered.• Paediatric asthma = will launch in

Jun 19.• Primary care data available in

Wales.

Reporting• National and regional reports

annually/six-monthly (as appropriate).__________________________________

• Will have 6-8 run-charts for all audits. • Adult asthma: First chart launched in May 19

• PR: First chart launching in Summer 19

• CYP asthma: First chart launching in Sept 19

• COPD: 6 charts available

Moving to real-time dataHospital/service level data benchmarked against the national average

Only viewable by registered web tool users

Updated every 15 minutes from data entered into the audit

Improvements in real-timeKey audit indicators Feb

2017April2019

% change

Patients receiving NIV within 2 hours of arrival 19.2% 24.8% 5.6%

Patients receiving respiratory review by a member of the respiratory team within 24 hours of admission 49.0% 72.6% 23.6%

Current smokers prescribed smoking cessation pharmacotherapy 24.0% 54.5% 30.5%

Patients prescribed oxygen to target saturation 95.9% 97% 1.1%

Patients with a spirometry result available 37.0% 49.8% 12.8%

Patients receiving a discharge bundle 48.6% 87.6% 39%

Aims for today• Understanding your data and

service – reflecting on your own service and data to identify areas for change.

• Familiarisation with selected QI methodologies in context –developing an aim and using the model for improvement.

Aims for today – part 2• To network with colleagues

to share expertise and examples of best practice.

• To leave the workshop with an action plan to implement and evaluate improvement in your service.

Ice-breaker

Ice breaker• The previous workshop highlighted five common

barriers to setting up a QI project:

• Time• Money• Staff & resources• Resistance to change• Lack of QI knowledge

• Use your phone to go to pollev.com/nacap

• Rank the barriers from easiest to hardest to change (easiest at the top)

Ice breaker

• What could you do locally to overcome the barrier ranked easiest to change?

Type your answer into the box in the online poll. Enter as many solutions as you like (one at a time).

• What could you do locally to overcome the barrier ranked hardest to change?

Ice breaker

Using NACAP data to understand your serviceProf Mike Roberts

Data collection

• QI is almost impossible without (good) data

• We know that collecting data is time-consuming and challenging. Successful data collection models include:• Data collection rotas• Dedicated staff member for entering data• Working with coding departments to get notes rapidly• Completing audit questions during the patient’s admission

How to access your data1) Go to nacap.org.uk2) select your audit and

log-in3) Click on the ‘reports’

tab 4) You can also ‘export’

all your patient level data if you want to have a closer look

Run charts – a poll • Use your phone to go to pollev.com/nacap

• What is a run-chart?

Run charts – overview • A run chart is a line graph of data for a particular

variable (e.g. sales of books about QI) plotted over time.

• Allows us to:– identify trends or patterns e.g. sales of books about QI are

increasing or decreasing– compare a performance measure before and after

implementation of a change to measure its impact– compare local performance to a bigger group e.g. sales in

one shop compared to a regional or national average

Run charts – interpretation • Axes:

– Y-axis = indicator to be measured

– X-axis = time

Run charts – interpretation • General things to look for:

1) Trends: are consecutive points going up or down?

2) Cycles: is there a pattern? 3) Erratic chart: are the data all over

the place? Is this about performance or about data entry?

4) Aberrations: is there a month where performance is great or terrible? What does this mean?

• What external factors may influence what the run chart is showing?

• Use your phone to go to pollev.com/nacap Getting worse?

Getting better?

Using run-charts to identify a change priority Performance is declining (trend)

Using run-charts to identify a change priority Performance is erratic

Using run-charts to identify a change priority Performance is consistently below average

What does this tell us?• Sales have gone

down (no surprises there) but why?

• There may be more to it:• No new books• Out of stock• No interest in QI

• How do you find out the reason?

Let’s look at a respiratory example

What’s the problem? • British Thoracic

Society (BTS) NIV quality statements: – Patients who meet

evidence-based criteria for acute NIV should start NIV…within 2 hours of hospital arrival.

• Use your phone to go to pollev.com/nacap

Identifying the right thing• If you aren’t sure whether

change is needed, take a ‘deep dive’ into your patient level export

• Look at the metric at hand:– Is data missing?– Are there errors?– Is all as it appears?

Process mapping• Once you’ve identified a problem (before you

think about what to change), it can be useful to learn more about your service

• Tool = process mapping• Allows you to understand

the entirety of a process • Identify areas for

improvement

Process mapping - NIVStep 1

• Patient admitted to A&E• Time 0

Step 2• First assessment (usually by A&E team)• Time to first assessment……………………………………………………………………………..

Step 3• A&E institutes investigations and treatment. Referral to medical team • Time to medical team review…………………………………………………………………….

Step 4• Assessment by medical team. Decision to commence NIV• Time to decision for NIV…………………………………………………………………………….

Step 5• NIV commenced. Limiting factors: availability of machine, might need reviews by ITU/Respiratory• Door-to-mask time……………………………………………………………………………………

Step 6• Patient admitted, ideally referred to Respiratory team• Time to Respiratory review………………………………………………………………………….

47.79 minutes

182.65 minutes

254.72 minutes

277.19 minutes

738.50 minutes

Process mapping – in real life

Analysing the process map Are we doing the right thing? (is it

clinically effective) Are we doing them in the right order? Is the right person doing it? How co-ordinated is the patient’s

journey? What information do we give to

patients at what stage? Is the information useful?

Baseline measurement: how often / how many / how much?

Variability in processes should only be driven by the needs of

the patient and not the preferences of the practitioners

Look for areas for improvement Is the process

standardised? Are steps repeated or out

of sequence? Are there steps that do

not add value? Are there steps where

errors occur frequently?

Table work• What can be improved?

– Look at the run-chart on your table

– What does this chart tell us is happening?

– What would the next steps be?

• Feedback

4a 4b

• Randomised Coffee Trial

– What has brought you here today?

– What improvement would you like to make in your hospital/service?

– Share some learning about undertaking an improvement project!

Coffee break

Developing a QI aimDr James Calvert

Developing an aim

• Agree your aim – make it SMART

• Use your data to generate it

• Make it patient-centred

S • Specific

M • Measurable

A • Achievable

R • Realistic

T • Time bound

What is a good aim statement?1) Brief - A few sentences which

explain everything needed. Normally this is honed over time

2) No technical talk – No three letter acronyms, or overly technical language

3) Data – Show the size of the problem or its impact

4) Data – Show the cost of the problem, what can be saved etc.

5) Explain what can be done – This is not ‘the answer’ but is about the scope of the project and timescale

• Not ‘we aim to improve our specialist review time’, but:

• ‘We aim to improve the number of patients receiving a discharge bundle from 60% to 70% within 3 months’

Moving from your data to your aim

• Use your run charts

• Use your exports

• What can you do?

• Where do you want to be?

Using driver diagrams• A driver diagram is a visual of

what ‘drives’ the achievement of an improvement goal/aim.

• Has three or more levels, including: – a goal or aim– the high-level factors that you need to

influence in order to achieve this goal (‘primary drivers’)

– specific projects and activities that would act upon these factors

Developing a driver diagram• Primary drivers:

– These are the big topics or areas that you will need to work on to achieve your aim

– Should include all key areas of the system that you will need to influence

• Secondary drivers:– Each Primary Driver could have

Secondary Drivers. These are what would need to be in place to positively influence the Primary Driver

– The difference between primary and secondary drivers is one of importance.

Driver diagram - example

To increase the number of patients receiving a respiratory

review within 24

hours from 50% to 60% by the end of the next

quarter

Rapid and appropriate diagnostic testing in

A&E

Improve systems for referral across teams (including treatment

induced referral)

Up-skill all members of respiratory team to

provide review

Increase frequency of respiratory rounds

Design concise guideline on appropriate tests

Make sure ED and AAU team have bleep numbers of on call respiratory specialist team member

Training session on discharge bundle and best practice

Ensure there is an early morning referral round 6 days a week

Aims Secondary driversPrimary drivers

Three types of measures

Outcome Measures• Voice of the service user• Other measures of how

the system is performing

Process Measures• Voice of the workings of

the system• Are the parts/steps

performing as planned?• Have you considered

exclusions and exceptions?

Balancing Measures• Looking at a system from

different directions/dimensions

• What happens to the system as we improved outcomes/process measures (unanticipated factors/other factors)?

Table work• Develop an aim for your

service based on your audit data

• Use the driver diagram template to identify drivers for your improvement aim

6b 6c6a5

Small tests of changeDr James Calvert

Why test changes?• To increase the belief that the

change will result in improvements • To learn how to adapt the change to

conditions in your setting• To evaluate the costs and ‘side-

effects’ of changes• To minimize resistance when

spreading the change throughout the organisation

To plan your change, it is important to regularly measure and study your activity using:

Model for improvement

What are we trying to accomplish?

How will I know that a change is an improvement?

What changes can we make that will result in improvement?

Act Plan

DoStudy

Aim

Measure

Change

Rapid cycle improvement

The model for improvement

PDSA Cycles

Act Plan

DoStudy

• Objective• Questions and

predictions (why)• Plan to carry out the

cycle (who, what, where, when)

• Carry out the plan• Document problems and

unexpected observations• Begin analysis of the

data

• Complete the analysis of the data

• Compare data to predictions

• Summarise what was learned

• What changes are to be made?

• Next cycle?

Examples from experience

Repeated Use of the Cycle

Hunches Theories

Ideas

Changes that result in

improvement

A PS D

A PS D

Examples of PDSA Cycles

Not enough patients being seen by a member of the respiratory team in 24 hours

A PS D

A PS D

Cycle 1: laminated poster with respiratory contact details placed in ED and admission ward

Cycle 2: Instigate 2 x respiratory rounds of A&E per day

Cycle 3: Education event provided to ED and admission staff

Cycle 4: Instant alert for known COPDpatients to respiratory team on arrival

Increased number of patients reviewed within 24 hours

Move quickly to testing changes• Year• Quarter• Month• Week• Day• Hour

‘What tests can we complete by next Tuesday?’

Measuring change

Cycle 1

Cycle 4

Cycle 3

Cycle 2

Lunch

Local case study: Improvements in a community pulmonary rehabilitation serviceDr Dennis WatConsultant Chest PhysicianLiverpool Heart and Chest Hospital

Topics to cover

Knowsley Community Respiratory Service (KCRS)

Quality improvement in Pulmonary Rehabilitation (PR)

Access to PR

Quality of PR

Outcomes of PR

• 2nd most deprived local authority in England

• Reported prevalence of COPD in Knowsleyo 5,100 patients 2 x that of national averageo COPD prevalence is the 2nd highest rate in the North

West and the 4th highest rate nationally

• 8 % of all deaths in Knowsley are due to COPD (110/year)o 2.5 x that of national average

• Smoking prevalence in Knowsley-27% (highest in the North West)

• 2nd highest smoking attributable mortality rate in the North West

Knowsley COPD problem

Components of community

respiratory service

Diagnostic service

Consultant-led MDT clinic

Oxygen Service

Counselling

Early supported discharge

Rapid response service

Pulmonary rehabilitation & Chest physiotherapy

Admin Hub

Average waiting time

was 3 months250 referrals

187 (75%) underwent initial

assessment

92 (49%) completes

95 (51%) failed to

complete

63 (25%) failed to attend initial assessment

All declined to attend

Local PR issues: 2011

Block programme

Poor admin support

Low staff morale

Poor staffing level

Hospital based

Lack of transport

Local PR issues: 2011

PAYMENT BY RESULT

KPI HIGH ADMISSION RATE

What did we do?

Act Plan

DoStudy

• Objective• Questions and

predictions (why)• Plan to carry out the

cycle (who, what, where, when)

• Carry out the plan• Document problems and

unexpected observations• Begin analysis of the

data

• Complete the analysis of the data

• Compare data to predictions

• Summarise what was learned

• What changes are to be made?

• Next cycle?

PDSA Cycles

Step 1

Change to a rolling design

Annual plan to monitor service performance

Increase staffing level

Full education pack

Life-style choices

Merge cardiac and pulmonary rehab

Home PR programme

PR open to all patients with chronic respiratory conditions

User friendly self-referral forms

Consistent communication Patients define their own goals

MRC 1 and 2 accepted for the education component or a short course for exercise advice

PR is offered at every patient contact

Knowsley Respiratory ServicePulmonary Rehabilitation Service

Knowsley PR programme

Hospital for oxygen patients

Huyton Leisure Centre

Stockbridge Leisure Centre

Whiston Town Hall

Halewood Leisure Centre

Kirkby Leisure Centre

Home based PR

5 days per week, rolling programme

• Included aerobics, cycling groups, yoga, dancing, community walk, aquarobics, Nintendo Wii sessions in conjunction with the traditional exercises

• Community engagement• Engagement with Activity for life and local BLF group

• In 2014o 336 patients commenced PR (completion rate of 75.8%)o 100% of patients met their expectations and achieved their goals set pre-

rehabo 79% found the programme helpfulo 96% found the service easy to access

ERS 2014

‘Lifestyle’ options

Santa Walk

Referrals accepted & PR commenced

Referrals accepted & PR commenced

Completion rates

Completion rates

Health Outcomes

• 88.58% of eligible patients were offered PR

• Increased the number of patients enrolling onto PR year on year

• 98.8% of patients completed PR

98.59% 93.22% 96.23% 88.46%

Knowsley PR KPI 2017/18

Referrals received

Average wait 25 days

84% of patients enrolled within 90 days

85% PR assessments being held in leisure centers

‘Holding list’ for patients awaiting further investigations, procedures, holidays

Optimisation of drug treatment, management of co-morbidities, and the promotion of smoking cessation and winter vaccination

2017/18

Patient feedback

Further improvementsSocial identity

Written, individualised exercise plan at discharge

PGD medications

Merge cardiac and

pulmonary rehab

Inhouse smoking cessation

service

PAM MyCOPD app

You: What do you do when you have to walk through a storm?

Alexa: When you walk through a storm, hold your head up high!

Creating your action planDr James Calvert

To plan your change, it is important to regularly measure and study your activity using:

Model for improvement

What are we trying to accomplish?

How will I know that a change is an improvement?

What changes can we make that will result in improvement?

Act Plan

DoStudy

Aim

Measure

Change

Rapid cycle improvement

The model for improvement

Table work • Use the drivers from your

driver diagram to identify ideas for change

• Develop an action plan to take back to your service

• Provide feedback

7b7a

Coffee Break

Effective stakeholder engagement in QI

Prof John Hurst

Aim of session • Understand theory of stakeholder engagement

• Review some useful tools to facilitate engagement

• Look at patient priorities in your clinical area

• Generate plan to engage patients better in QI

Why engage others in QI?

• Log into the online poll and tell us who is important to engage with in for your QI project to be successful

• pollev.com/nacap

Who do we want to engage with?

How to engage others in QI?Approaches Explanation

Stakeholder Mapping Identifies who stakeholders are - who has influence on or interest in your project.

Stakeholder Analysis Identifies the needs and concerns of these different stakeholders and groups.

Stakeholder Engagement

Helps you plan how stakeholders can be part of the project team.

This engagement can be guided by 4PI National Involvement Standards - Principles, Purpose, Presence, Process and Impact.

Stakeholder Communication Enables you to share updates and listen to comments, in dialogue with different groups.

Stakeholder Management Helps you take proactive steps to change the opinions, attitudes and actions of stakeholders.

Patient and public involvement

Who?

Patients

Potential patients

Carers

Health/ social care

service users

Voluntary sector

• Different perspective

• They have a right to be involved

• Power of persuasion

• Improves outcomes of QI work

Why involve patients?

• PPI is…– Patients and the public being members of the

improvement team – Working with patients to co-design or redesign a

service or elements of the service – Working with patients to prioritise areas of

improvement

Patient and public involvement

• PPI is not…– Designing improvements to a service without including

patients in the planning– Presenting your service improvements to members of

the public– Collecting data from patients based on measures

which matter to the service (without understanding what really matters to the patients)

Patient and public involvement

• Development of patient priorities

• Review of all audit materials, including datasets

• Co-design of patient reports

• Co-design of communications e.g. infographics

• Active members of programme governance groups

PPI in NACAP

PPI in practice Patient panel member – ‘Mrs A’

Understanding your data

• Meet with CCG to discuss COPD pathway

• Interpreting data

PPI in practice Developing an aim

• Identify areas of improvement from their perspective

• Patients asked what they would like to see as part of their care pathway

S • Specific

M • Measurable

A • Achievable

R • Realistic

T • Time bound

PPI in practice Identifying drivers to improvement

• Identifying drivers and barriers to change

• Patients can see the whole ‘Elephant’

PPI in practice Implementing change ideas

• GP, medic and patient training

• Funding applications

• Empowered to speak directly to CCG

Act Plan

DoStudy

PPI in practice Outcomes• New services commissioned

• Pathway re-design implemented Care is perceived by patients as more responsive to their needs

For Mrs A• Used to be in and out of hospital on a regular basis – now is mostly

treated at home

• Develop skills in public speaking and training

• Is now able to ask for better care

PPI in practice Mrs A’s Top Tips

“Care is more responsive to the individual needs of patients, when they are involved in designing how care is provided”

“Whichever patient gives you the most grief, is the perfect patient to help you improve your service!”

Table work• Review adult patient

priorities for your area of work (CYP audit patient priorities to come)

• Develop an action plan to better involve your patients in QI

• Provide feedback

87b

Next steps and conclusionsProf Mike Roberts

Next steps and conclusions• Follow up• Buddy system and peer review • Collaboratives

• Feedback form - please complete them to:• Help us improve• Help us understand what follow-up

would help you most!

Thank you!