Q community event 2019Session 1A - Building organisational and system-wide
approaches to improvement
13 November 2019
Agenda
1. Chair’s welcome - Tim Horton, Assistant Director, The Health Foundation
2. The Improvement Journey report - Bryan Jones, Improvement Fellow, The Health Foundation
3. The ELFT approach to quality - Amar Shah, Chief Quality Officer, East London NHS FT
4. GSTT’s improvement journey - Neil Goulbourne, Deputy Director of Improvement, Guy’s & St.
Thomas’ NHS Foundation Trust
5. Rapid responses
• Erin Payne, Head of QI, Yorkshire Ambulance Service NHS Trust
• Frances Wiseman, Head of Transformation and Delivery, Portsmouth Hospitals NHS Trust
6. Comments and questions from the floor
13.11.19 Building organisational and system wide approaches to improvement
Key questions for this session• What is an organisational approach to improvement, and why do they matter?
• What is involved in planning, implementing and sustaining an organisational approach to
improvement?
• What capabilities and capacity do organisations need to embark on their journey?
• How should organisations assess their ‘readiness to improve’?
• To what extent do organisations’ size, location, care sector and ‘improvement maturity’
matter when it comes to deciding the pace, shape and direction of their approach to
improvement?
• How do organisational level approaches to improvement relate to system level
improvement approaches?
• What external support do organisations and systems need on their improvement journey?
13.11.19 Building organisational and system wide approaches to improvement
The Improvement JourneyBryan Jones, Improvement Fellow, The Health Foundation
13.11.19 Building organisational and system wide approaches to improvement
Health Foundation learning on organisational and system wide improvement
What is an organisational approach to improvement?
A long-term initiative to embed a culture of continuous improvement across an
organisation, involving:
• an improvement vision supported at all levels, which is realised through;
• a coordinated programme of interventions to improve care pathways and systems
13.11.19 Building organisational and system wide approaches to improvement
What are the key enablers?
• Leadership and governance: visible board leadership; improvement activity
aligned with organisational strategy
• Infrastructure and resources: data, equipment and resources available at team
level to plan and deliver improvement
• Skills and workforce: improvement capability
building programme open to all staff
• Culture and workforce: supportive, collaborative
and inclusive workplace culture
13.11.19 Building organisational and system wide approaches to improvement
Why does it matter?
A coordinated, aligned organisational
improvement approach:
• Avoids safety risks of siloed microsystem
level improvement
• Enables efficient use of staff time and
resources
• Provides means to tackle ‘big hairy’
systemic problems
• Enables creation of a workplace culture
conducive to improvement
13.11.19 Building organisational and system wide approaches to improvement
Why does it matter?NHS Long Term Plan
‘A programme to build improvement capability exists in 80% of the trusts rated ‘outstanding’
NHS Trust quality strategies – three examples
‘Our ambition is to maintain our outstanding grading and our focus on continuous QI will help us
achieve this aim.’
‘Outstanding trusts have one thing in common; a well-led, embedded, staff and patient driven QI
approach. This trust has committed to this QI agenda.’
‘A large scale, integrated improvement programme, encompassing strategic change, population
health, digital transformation, service and productivity improvement, workforce redesign, OD, QI
and patient involvement is being proposed to drive the trust’s actions over the next 3 years.’
13.11.19 Building organisational and system wide approaches to improvement
Characteristics of organisations struggling to improve quality
13.11.19 Building organisational and system wide approaches to improvement
Systematic
review by
Vaughn and
Saint et al
BMJ Qual Saf
2019
Assessing readiness
1 Securing board support
2
Sustaining an organisation-wide approach
6Aligning activity5
Developing improvement skills and infrastructure
4
Securing wider organisationalbuy-in
3
The improvement journey
The ELFT approach to quality
Dr Amar Shah, Chief Quality Officer
DrAmarShah
Mental health servicesNewham, Tower Hamlets, City & Hackney, Luton & Bedfordshire
Forensic servicesAll above & Waltham Forest, Redbridge, Barking, Dagenham, Havering
Child & Adolescent services, including tier 4 inpatient service
Regional Mother & Baby unit
Community health services Newham, Tower Hamlets &
Bedfordshire
IAPTNewham, Tower Hamlets,
Richmond and Bedfordshire
Primary care
AIMTo provide the
highest quality
mental health and
community care in
England by 2020
Engaging, encouraging &
inspiring
Developing improvement
skills
Embedding into daily work
QI Projects
1. Targeting / segmenting communication for different groups (community- based staff, Bedfordshire & Luton staff)
2. Sharing stories – newsletters, microsite, presenting internally3. Celebration – awards, conferences, publications, internal
presentations4. Share externally – social media, Open mornings, visits, microsite5. Work upstream – trainees, regional partners, key national and
international influencers
1. Pocket QI for anyone interested, extended to Beds & Luton2. Refresher training for all ISIA graduates3. Improvement Science in Action waves4. Online learning options5. Develop cohort and pipeline of improvement coaches6. Leadership and scale-up workshops for sponsors7. Bespoke learning, including Board sessions & commissioners
1. Learning system: QI Life, quality dashboards, microsite2. Standard work as part of a holistic quality system3. Job descriptions, recruitment process, appraisal process4. Annual cycle of improvement: planning, prioritising, design and
resourcing projects5. Support staff to find time and space to improve things6. Support deeper service user and carer involvement
Directorate-level priorities- Defined through annual cycle of planning- Most local projects aligned to directorate priorities
Trust-wide strategic priorities1. Reducing inpatient physical violence2. Improving access to community services3. Enjoying work4. Shaping recover in the community5. Value for money
Experts by experience
All staff
Staff involved in or leading QI projects
Sponsors
Board
Estimated number needed to train = 4000Needs = introduction to QI & systems thinking,
identifying problems, how to get involved
Estimated number needed to train = 1000Needs = Model for improvement, PDSA,
measurement and using data, leading teams
Estimated number needed = 50Needs = deep understanding of method & tools,
understanding variation, coaching teams
Needs = setting direction and big goals, executive leadership, oversight of improvement,
understanding variation
Estimated number needed to train = 10Needs = deep statistical process control, deep
improvement methods, effective plans for implementation & spread
477 completed Pocket QI so far. All staff receive intro to QI at
induction
690 graduated from ISIA in 6 waves. Wave 7 in 2017-18.
Refresher training for ISIA grads.
53 QI coaches trained so far, with 35 currently active. Third cohort of
20 to be trained in 2017
All Executives have completed ISIA. Annual Board session with IHI &
regular Board development
Currently have 6 improvement advisors, with 3 further QI leads in
training
Internal experts (QI
leads)
Bespoke QI learning sessions for service users and carers. Over 95
attended so far. Build into recovery college syllabus
Needs = introduction to QI, how to get involved in improving a service, practical skills in
confidence-building, presentation, contributing ideas
QI coaches
Needs = Model for improvement, PDSA, measurement & variation, scale-up and spread,
leadership for improvement
58 current sponsors. All completed ISIA. Leadership, scale-up & refresher QI training in 2017
Psychology trainees – Pocket QI, embedded into QI project teams with 4 bespoke learning sessions
Nursing students – Intro to QI delivered within undergraduate and postgrad syllabus, embedded into QI project teams during student placements
Wor
king
upst
ream
qi.elft.nhs.uk
Change in leadershipbehaviours
“Go see”“Gemba”Executive WalkRounds
Use of data to guide decision-making
Stop solving problems at the top
Give people time and space to solve complex problems
Manage the expectationsPaying
personal attention
QI ResourcesService User Input
Support around every team
Project Sponsor QI Coach
QI Forums
QI Team
UCL
175.462
102.625
LCL
60
80
100
120
140
160
180
200
220
Jan-
13Fe
b-13
Mar
-13
Apr-1
3M
ay-1
3Ju
n-13
Jul-1
3Au
g-13
Sep-
13Oc
t-13
Nov-
13De
c-13
Jan-
14Fe
b-14
Mar
-14
Apr-1
4M
ay-1
4Ju
n-14
Jul-1
4Au
g-14
Sep-
14Oc
t-14
Nov-
14De
c-14
Jan-
15Fe
b-15
Mar
-15
Apr-1
5M
ay-1
5Ju
n-15
Jul-1
5Au
g-15
Sep-
15Oc
t-15
Nov-
15De
c-15
Jan-
16Fe
b-16
Mar
-16
Apr-1
6M
ay-1
6Ju
n-16
Jul-1
6Au
g-16
Sep-
16Oc
t-16
Nov-
16De
c-16
Jan-
17Fe
b-17
No. o
f Inc
iden
tsIncidents resulting in physical violence (ELFT excluding Luton and Bedfordshire) - C Chart
150
250
350
450
550
650
750
850
2013 2014 2015 2016
No. o
f Inc
iden
ts
Physical violence to staff (per 100,000 occupied bed days)
150
250
350
450
550
650
750
850
2013 2014 2015 2016
No. o
f Inc
iden
ts
Physical violence to patients (per 100,000 occupied bed days)
42%
31.73%24.38%
23.52%
20.32%
UCL
LCL
15%
17%
19%
21%
23%
25%
27%
29%
31%
33%
35%
37%
39%
Jan-
14
Feb-
14
Mar
-14
Apr-
14
May
-14
Jun-
14
Jul-1
4
Aug-
14
Sep-
14
Oct
-14
Nov
-14
Dec-
14
Jan-
15
Feb-
15
Mar
-15
Apr-
15
May
-15
Jun-
15
Jul-1
5
Aug-
15
Sep-
15
Oct
-15
Nov
-15
Dec-
15
Jan-
16
Feb-
16
Mar
-16
Apr-
16
May
-16
Jun-
16
Jul-1
6
Aug-
16
Sep-
16
Oct
-16
Nov
-16
Dec-
16
Jan-
17
DN
A %
1st face to face appointments non-attendance (10/13 teams) - P Chart
UCL
1,021.711,213.13
1,284.57
LCL
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
Jan-
14
Feb-
14
Mar
-14
Apr-
14
May
-14
Jun-
14
Jul-1
4
Aug-
14
Sep-
14
Oct
-14
Nov
-14
Dec-
14
Jan-
15
Feb-
15
Mar
-15
Apr-
15
May
-15
Jun-
15
Jul-1
5
Aug-
15
Sep-
15
Oct
-15
Nov
-15
Dec-
15
Jan-
16
Feb-
16
Mar
-16
Apr-
16
May
-16
Jun-
16
Jul-1
6
Aug-
16
Sep-
16
Oct
-16
Nov
-16
Dec-
16
Jan-
17
No.
of R
efer
rals
No. of referrals received (10/13 teams) - I Chart
60.66
53.17
44.51
49.42
UCL
LCL
35
40
45
50
55
60
65
70
Jan-
14
Feb-
14
Mar
-14
Apr-
14
May
-14
Jun-
14
Jul-1
4
Aug-
14
Sep-
14
Oct
-14
Nov
-14
Dec
-14
Jan-
15
Feb-
15
Mar
-15
Apr-
15
May
-15
Jun-
15
Jul-1
5
Aug-
15
Sep-
15
Oct
-15
Nov
-15
Dec
-15
Jan-
16
Feb-
16
Mar
-16
Apr-
16
May
-16
Jun-
16
Jul-1
6
Aug-
16
Sep-
16
Oct
-16
Nov
-16
Dec
-16
Jan-
17
Aver
age
Wai
ting
Tim
e /
Day
s
Average waiting time from referral to 1st face to face appointment (10/13 teams) - X-bar Chart
- Testing begins - 3 teams leave the collaborative- 2 new teams join the collaborative - New DNA operational definition
Legend
Access to Services Collaborative
19%
36%26%
Periodic checks to ensure
the service is meeting the
needs of the customer/population
Actions to address gaps
identified
Identify clear measures of quality for the service,
and monitor these over time.
Take corrective action when
appropriate
Internal vigilance to hold
gains made through improvement
Identify the needs of the customer/ population
Develop service models to meet
the needs
Put in place structures and
processes to manage the
service
Identify what matters
most
Design project and bring
together a diverse team
Discover solutions through involving
those closest to the work, test ideas,
implement and then scale up
GSTT’s Improvement JourneyNeil Goulbourne, Deputy Director of Improvement,
Guy’s & St. Thomas’ NHS Foundation Trust
About GSTT
• 800 years old
• 17,000 staff
• 1,334 beds
• 2.6 million patient contacts
• 6,492 babies
• 796,000 patient contacts in community
services.
• 50 outreach clinic locations
Improvement and transformation at GSTT
+
• Evelina improvement
team
• Community transformation
team
• CLIMP Siemens
• Design thinking
• Patient safety and QI team
• 75 audit leads
• …
+
We knew we could do better
Confusion
for staff
CQC
guidance
QI not most
people’s ‘go
to’
Dwindling
impact
Our QI task and finish group
Strategy
• 14 teams
• 8 weeks
• Appreciative enquiry
• 3 workshops
• Desktop research
• Interviews
Implementation
plan
• 8 weeks
• 3 workshops
• More
interviews!
The GSTT QI System
Implementation plan
• Two model directorates – co-design
• Spread in pairs and triplets ahead of EHR
• Build corporate team including expertise
• QI coaches will lead EHR implementation
• Look for opportunities to spread faster
• Get external support but using our materials
Where are we now?
What have we learnt?
A movement for change in a complex environment
Relationship between corporate and local teams
Make the most of existing assets
Expertise into the corporate team
Avoid copying anatomy of exemplars
Make it practical
Rapid responses from Q members• Erin Payne, Head of QI, Yorkshire Ambulance Service NHS Trust
• Frances Wiseman, Head of Transformation and Delivery,
Portsmouth Hospitals NHS Trust
Key questions for this session• What is an organisational approach to improvement, and why do they matter?
• What is involved in planning, implementing and sustaining an organisational approach to
improvement?
• What capabilities and capacity do organisations need to embark on their journey?
• How should organisations assess their ‘readiness to improve’?
• To what extent do organisations’ size, location, care sector and ‘improvement maturity’
matter when it comes to deciding the pace, shape and direction of their approach to
improvement?
• How do organisational level approaches to improvement relate to system level
improvement approaches?
• What external support do organisations and systems need on their improvement journey?
13.11.19 Building organisational and system wide approaches to improvement
Thank you