A Year in an Hour. NIHR CLAHRC Northwest London. Collaboration for Leadership in Applied Health Research and Care Northwest London

Transcription

1 A Year in an Hour Prof Julie Collaboration for Leadership in Applied Health Research and Care The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Northwest London Is hosted by Chelsea and Westminster Hospital NHS Foundation Trust and academically led by Imperial College London, in partnership with

2 Today Get an insight into the practical reality of delivering change in healthcare Live an 18 month project in 60mins Draw on this learning in your improvement work: Know what to expect and prepare to expect the unexpected appropriately to anticipate and mitigate risks

3 Model for improvement (including PDSA) Outlines key questions to reflect on to make improvement Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Aims Measures Changes to test Testing change

4 BMJ Quality & Safety 1)Tests of change 2)Prediction 3)Use of sequential cycles 4)Start small scale 5)Use of data over time 6)cumentation 150,000 downloads! Taylor, McNicholas et al. BMJ Quality and Safety,2013

5 Iterative PDSA Cycles Its simplicity belies its sophistication Berwick 1996 Orinic & Shojania, BMJ Q&S 2014 Reed and Card, BMJ Quality and Safety, 2015 Failure to apply in rigorous and tailored application

6 4 Healthcare Sites 65 Interviews 70 Observation hours Over 500 PDSA cycles International Qualitative v

7 Improvement initiative example: Improving discharge from hospital to community

8 Northfields Hospital Northfields Hospital is a district general hospital serving a population of around 465,000 people with approximately 2,400 staff and around 500 beds. The hospital provides urgent and emergency services, Medical care (including older people s care), surgery, critical care, maternity and gynaecology, services for children and young people, end of life care and outpatients and diagnostic imaging. The last staff survey showed staff were positive about Northfields Hospital as a place to work and a higher proportion of staff would recommend the hospital as a place to be treated. Key measures of performance such as the 4-hour Accident & Emergency target, cancer waiting times targets and referral to treatment targets continues to cause pressure for the Trust. A strong team of experienced clinical leaders work with all staff to continue to provide high quality care for patients.

9 Understanding change & embracing complexity Ambulance Emergency Department Emergency Care 4 hour performance standard wnstream Ward Acute Medical Unit Community

10 Patients Viewpoint

11 It is a terrible feeling, thinking that you could have done something differently"

12 Towards improvement...focusing on the change you want to make

13 Change idea: Discharge checklist Successful checklist used in other organisation Consists of: Review of final items of care Medication check Patient information provision GP follow-up appointment Transport arrangement Setting: Acute care ward Multidisciplinary Team What would your first step be?

14 PDSA series 1 End of series - checklist considered to be fit for purpose for our hospital 2 weeks Quick (not dirty) tests of change Reed and Card 2015

15 Towards improvement...putting the change into practice

16 Managing the Exploding PDSA A single PDSA which results in large amount of learning, identifying barriers and areas for further improvement

17 Small Group Exercise 10 minutes Designate someone to feedback 1. Read the PDSA series - What happened? 2. Read the quotes - What different views were expressed by staff? 3. What reflections do you have on what this means for people conducting improvement initiatives?

18 Whole Group Exercise Feedback from each PDSA cycle: 1. Read the PDSA series - What happened? 2. Read the quotes - What different views were expressed by staff? 3. What reflections do you have on what this means for people conducting improvement initiatives?

19 Towards improvement...understanding what your change idea is dependent on

20 PDSA #1 Consultant For so many months before I cannot remember having a nurse with me on a ward round. For, I don t know, years, probably. I mean occasionally, but not Almost by chance, really, and junior doctors, having them with you on a ward round was also reasonably infrequent I m sick of doing ward rounds on my own

21 PDSA #2 Nurse So it was chaos and, you know, the nurses at the end of the day, they were going to the notes: oh my goodness, Dr Bell's been in. And I didn't know he's been in. And we would be standing at 9 o'clock at a board round scratching our heads, you know - the team thinking, when will this person be discharged? What are we planning for? Meanwhile, the senior decision-makers out on the ward are on their own. So it was just the system was broken.

22 Towards improvement...working with constraints...what can you stop doing?

23 PDSA #3 Consultant But I think the frustration in it all is around, like, they have got double the paperwork to what they had three years ago by all these initiatives. And, you know, in many ways that doesn't sit right. The nursing staff are already on their knees, stretched to the limit, being told to do this, that and the other with no extra resource. So if you want people to do extra things, you have to give them the resource to do that, be it time, money or otherwise, but you can t just expect people to absorb it into an already overloaded work plan.

24 Towards improvement...understanding what going on beneath the surface

25 PDSA #4 Consultant Some people have said they [never] have a nurse [with them on ward round]. And then you ask the nurses, and they say, that s because that person never comes when they say they re going to, and quite a few of the consultants are still in the mode of, well, you know, I ll say when I m coming and they ll just have to fit in, so that s quite challenging.

26 Towards improvement...organisational contributions...peer-to-peer influence

27 PDSA #5 Improvement Manager: The biggest refinement was consistently applying the process It was, like...look, will you stop behaving badly? It was one of the consultants. who actually turned around and said, I was actually embarrassed to be a consultant last week when I came across two consultants arguing in a ward about this [in front of a patient]. And then [all of the] issues came out. And it's good that it did come out because after that, you know, other teams have started to work better, although we're still having to refine it. There's some underlying issues.

28 Towards improvement...understanding the next area for improvement...sustainability

29 PDSA #6 Clinical Director: So they have, as they say, ownership of, one, the problem and, two, they all accept the solutions because they have found them themselves as opposed to somebody else saying, what you need to do is that so, in those terms, it certainly, I think, it is successful, because there is now another large cohort of staff who are agreed upon what the issues are and many of the solutions that are required.

30 PDSA #6 Improvement Manager: There's a process there which the senior charge nurse, has had to be [very strict about] She's got a timetable: MDT ward round at that time, and at that time that's what happens, and at that time that's what happens. Because if they don't have that everything falls apart And then junior doctors come in and say, oh, I'll do it that way. She'll say, no, you do it this way.

31 Improve quality, timeliness and consistency of hospital discharge for patients Decision to discharge patient 4 Delivery of final items of care Appropriate discharge of patient from hospital 5 6 Delivery of appropriate clinical activities Pharmacy aware of discharge and medication provided Patient counselling Follow-up GP appointment arranged Timely transport arrangements Social support arrangements Discharge check list 7 1. Patient experience 2. Length of stay 3. Readmissions 4. Number of patients with estimated discharge date recorded 5. Time of day of discharge 6. Day of week of discharge 7. Discharge checklist completion Reed, McNicholas et al, BMJ Quality and Safety 2014

32 Physical function of patient Acute medical input Daily MDT changes Improve quality, timeliness and consistency of discharges for patients in ward X Decision to discharge patient 4 Delivery of final items of care 5 6 Appropriate discharge of patient from hospital Social assessment and support requirements AHP input wnstream services availability and awareness Discharge pre planned day in advance Internal communication of decision to discharge internally Delivery of appropriate clinical activities Pharmacy aware of discharge and medication provided Patient awareness of condition Follow-up GP appointment arranged Timely transport arrangements Social support arrangements Daily Board Rounds Blood Prioritisation Process Discharge check list Process for GP appointment booking 7 Discharge Letters to GP 1. Patient experience 2. Length of stay 3. Readmissions 4. Number of patients with estimated discharge date recorded 5. Time of day of discharge 6. Day of week of discharge 7. Discharge checklist completion Reed, McNicholas et al, BMJ Quality and Safety 2014

33 ion Effect Diagrams Agreeing a shared aim Identifying cause and effect chains Distributed measures to assess progress and impact Programme Theory Technical and social functions

34 How can it help? QI methods can help teams to anticipate and manage the unexpected Invest time in planning understand how proposed changes will fit with existing work Be aware of new learning that emerges problems you weren t aware of before, issues or concerns raised by staff Dealing with emotions takes time

35 Engaging people in conducting a single PDSA cycle Imagined Reality

36 Engaging people with PDSA Understand perspectives Acknowledge the practical reality of change Explore differences in opinion or conflicts Seek insights and feedback Create a shared understanding Improve change ideas Create motivation Maximise social capital Increase chances of sustained success

37 Learning NIHR CLAHRC Engaging people with tests of change over time Sustainability Change embedded as normal practice with no support from QI team Maintainability Change used reliably and consistently across intended population with support from QI team Scalability Change fits with daily routines and practices and works across all sites or settings Acceptability Change accepted by those who use is or are influenced by it Applicability Change works in variety of situations Usability Change works as intended Time

38 Engagement Learning NIHR CLAHRC Engaging people with tests of change over time Sustainability Maintainability Last adopters Scalability Acceptability Late majority Sceptics and resistors Low tolerance for rework and set backs Applicability Early majority Usability Early adopters Enthusiasts and supporters High tolerance Time

39 Creating safe environments for learning In order to successfully improve we need to learn In order to learn we will need to make mistakes In order to learn from mistakes we will need to encounter failure Emotionally it is hard to fail We aren t taught to embrace failure In order support people to fail (and succeed!) we need to create safe environments for failing

40 Change and learning Comfort Zone No learning No change Discomfort Zone uncertainty learning Panic Zone People close up they freeze they don t learn

41 Summary PDSA provides a safe environment for learning Starting as small as possible ning to anticipate and mitigate risks Building confidence before increasing scale Maximising learning opportunities Using social capital wisely To do PDSA well requires investment, humility and collaboration.

42 QI4U

43 Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Dr Julie