Leadership for quality improvement

Transcription

1 Leadership for quality qi.elft.nhs.uk

2 What is the context within which we lead?

3 What type of leadership behaviours are best suited for this context?

4 Culture is a set of shared, taken-for-granted implicit assumptions that members of an organisation hold and that determines how they perceive, think about and react to things. Edgar Schein (1992)

5 Reflects what an organisation values Co-created by all in the organisation Dynamic Every interaction reveals and shapes the culture Organisational culture Most important determinant is current and future leadership

6 Power to reward or punish Shape the work lives of others Leaders Control information & resources Make choices about structures

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11 Collective leadership means the distribution and allocation of leadership power to wherever expertise, capability and motivation sit within organisations The purposeful, visible distribution of leadership responsibility onto the shoulders of every person in the organisation

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13 Leadership for cultures of high quality care 1. Prioritising an inspirational vision and strategic narrative focused on quality 2. Clear aligned goals and objectives from Board to front line 3. Supportive people management 4. High levels of staff engagement 5. Continuous learning and quality improvement the responsibility of all 6. High levels of genuine team working and cooperation across boundaries

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15 @ELFT_QI The strategic case for change Make quality our absolute priority National drivers Enable our staff to lead change The economic climate Improving quality of care is our core purpose Of greatest importance to all our stakeholders Build on the excellent work already happening to improve quality The need to focus on a more compassionate, caring service with patients first and foremost More structured and bottom-up approach to improvement The desire to engage, free and support our staff to innovate and drive change Engaged and motivated staff leads to improved patient outcomes The need to do more with less improving quality whilst reducing cost

16 The culture we want to nurture A listening and learning organisation Empowering staff to drive improvement Increasing transparency and openness Patients, carers and families at the heart of all we do Re-balancing quality control, assurance and improvement

17 Assurance, control & performance management Research & innovation Quality improvement

18 Mental Models & Quality Theories Quality Control Monitor Key Process Indicators (KPI s) against targets Take Action when not meeting targets Regulatory approach Quality Assurance Inspection-looking for the Bad Apples Retrospective Review Risk Management Quality Improvement Process and system improvement Reduce Variation Align outputs to customer needs Continuous & part of daily work Science of Improvement Michael Pugh, 2014

19 Old Way, New Way Requirement, Specification or Threshold Action taken on all occurrences No action taken here Reject defectives Better Quality Old Way (Quality Assurance) Worse Better Quality Worse New Way (Quality Improvement)

20 AIM: To provide the highest quality mental health and community care in England by 2020 Build the will Build improvement capability Alignment QI Projects 1. Newsletters (paper and electronic) 2. Stories from QI projects - at Trust Board, newsletters 3. Annual conference 4. Celebrate successes support submissions for awards 5. Share externally social media, Open mornings, visits, microsite, engage key influencers and stakeholders 1. Build and develop central QI team capability 2. Online learning options 3. Pocket QI for those interested in QI 4. Improvement Science in Action waves 5. Develop cohort and pipeline of QI coaches 6. Bespoke learning, including Board sessions & commissioners 1. Embed local directorate structures to support QI 2. Align projects with directorate and Trust-wide priorities 3. Support staff to find time and space for QI work 4. Support deeper service user and carer involvement 5. Support team managers and leaders to champion QI 6. Align research, innovation, improvement and operations Reducing Harm by 30% every year 1. Reduce harm from inpatient violence 2. Reduce harm from pressure ulcers 3. Other harm reduction projects (not priority areas) Right care, right place, right time 1. Improving access to services 2. Improving physical health 3. Other right care projects (not priority areas)

21 @ELFT_QI Building the will for change Sentinel event Early small scale tests of QI methodology Visiting other organisations that successfully implemented QI Focus groups Trust board bespoke learning sessions

22 Build the will QI microsite the online hub for the programme has 80,000 page views to date qi.elft.nhs.uk Staff and service user newsletter reaches 5000 people every month AIM: To provide the highest quality mental health and community care in England by 2020 Bespoke QI learning events for staff, service users, commissioners, governors QI launch event and roadshows attended by over 1000 staff, service users and carers Annual QI conference attended by over 270 staff, patients and external partners ELFT experience day attended by over 70 international delegates QI visibility wall to describe programme & update on progress

23 Pocket QI commenced in October Aim to reach 200 people by Dec All staff receive intro to QI at induction Estimated number needed to train = 5000 Needs = introduction to quality improvement, identifying problems, change ideas, testing and measuring change 500 people have undertaken the ISIA so far. Wave 5 = Luton/Beds (Sept 2016 Feb 2017) 30 QI coaches graduating in January To identify and train second cohort in mid-late 2016 Currently have 3 improvement advisors, with 1.5 wte deployed to QI. To increase to 8 IA s in 2016/17 (6 wte). Estimated number needed to train = 1000 Needs = deeper understanding of improvement methodology, measurement and using data, leading teams in QI Estimated number needed to train = 45 Needs = deeper understanding of improvement methodology, understanding variation, coaching teams and individuals Estimated number needed to train = 11 Needs = deep statistical process control, deep improvement methods, effective plans for implementation & spread Experts by experience All staff Staff involved in or leading QI projects QI coaches Internal experts (QI team) Most Executives will have undertaken the ISIA. Annual Board session with IHI & regular Board development discussions on QI Needs = setting direction and big goals, executive leadership, oversight of improvement, being a champion, understanding variation to lead Board Bespoke QI learning sessions for service users and carers. Over 50 attended in Build into recovery college syllabus, along with confidence-building, presentation skills etc. Needs = introduction to quality improvement, how to get involved in improving a service, practical skills in confidence-building, presentation, contributing ideas, support structure for service user involvement

24 Working upstream with external partners to build capability around continuous improvement AIM: To provide the highest quality mental health and community care in England by 2020 Build improvement capability Face to face improvement training - hundreds of staff, services users, Governors to be trained over the next few years QI coaches- 30 staff to become coaches, spending 1 day/week supporting local QI projects IHI Open School online training resource available to all. Providing essential skills to support people leading quality improvement. Support for improvement work from the Trust s QI team Partnership with IHI on delivery of QI training to staff and Trust Board, and strategic guidance from IHI executive team

25 Support around your project team Project Sponsor QI Coach QI Team QI Forums Service User Input QI Resources

26 AIM: To provide the highest quality mental health and community care in England by 2020 Alignment

27 No. of new projects Our QI Projects No. of active projects per month

28 REDUCE HARM BY 30% EVERY YEAR RIGHT CARE, RIGHT PLACE, Right RIGHT Care, TIME Right Place, Right Time VIOLENCE REDUCTION PRESSURE ULCERS PHYSICAL HEALTH ACCESS TO SERVICES TH Collaborative Roman, Globe, Bricklane, Lea, Millharbour, Rosebank MHCOP Larch Lodge, Cedar Lodge, Sally Sherman Ward Forensics Clerkenwell, West Ferry Ward CAMHS Coborn Unit CHN EPCS Teams (North East, North West, Central, South) Multiple I/P Wards (Cazebon, Sally Sherman and Fothergaile) Children s All Community CAMHS, Adolescent MHT City & Hackney Adult Psychiatry CMHT, All CMHT s, Assertive Outreach, Rehab, Joshua, Conolly CHN / MHCOP Urgent Care Centre Forensics Woodberry, Victoria, Limehouse, Morrison Newham CMHT s, Newham Centre for Mental Health Children s Newham CFCS, CDC West Ham Lane, Community CAMHS TH, OT, Health Visiting C&H South CMHT, AOS & CRRT, North Team 1 Recovery/Primary Care CHN / MHCOP Newham Memory Service Psychological Older People Richmond / Newham, City and Hackney, Newham Psychological / LD Community Learning Disability Service Tower Hamlets Smoking Forensics, Millharbour

29 Is it making a difference?

30 Initial prototype unit - violence reduction across the acute adult mental health ward with highest levels of violence Time between events / days 05-Apr Apr May Jun Jun Jun Jun Jul Jul Jul Jul Aug Aug Sep Sep Oct Oct Oct Nov Nov Nov Nov Dec Jan Feb Mar Mar Apr May Jun Jun Jun Jul Aug Oct Dec Jan Jan Feb Mar Apr Jun Jul Aug-15 Time between incidents of physical violence on an inpatient adult mental health ward (Globe ward) T chart 50% reduction Testing in different conditions - Violence reduction across the three older adult mental health wards with highest levels of violence Time between incidents of physical violence on three older adult mental health wards T chart 63% reduction 8 days days 10 0

31 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 No. of Incidents Testing in different conditions - Violence reduction on a forensic male rehabilitation ward Incidents resulting in physical violence (Clerkenwell ward) - C Chart UCL LCL

32 QI Work begins No. of Incidents per 1000 OBD 16 Scaling up - Violence reduction over four adult acute mental health wards in Tower Hamlets Incidents resulting in physical violence (Acute wards only) per 1000 occupied bed days (OBD) - U Chart 14 UCL % reduction LCL BASELINE DATA (BEFORE) PDSA DATA (AFTER) Learning Set 1 Learning Set 2 Introduce safety culture bundle Learning Set 3 Learning Set 4 Learning Set 5: Safety Huddle outcomes Learning Set 6 & General Adult wards go smoke free Learning Set 7

33 06-Jan Jan Feb Feb Mar Mar Mar Apr Apr May May Jun Jun Jul Jul Aug Aug Sep Sep Sep Oct Oct Nov Nov Dec Dec Jan Jan Feb Feb Mar Mar Mar Apr Apr May May Jun Jun Jul Jul Aug Aug Aug Sep Sep Oct Oct Nov-15 No. of Incidents per 1000 OBD Impact at organisation-level Rates of physical violence across the organisation 12 Incidents resulting in physical violence (Trust-wide) per 1000 occupied bed days (OBD) - U Chart 11 UCL LCL % reduction across the Trust

34 Medication safety across all 6 older adult mental health wards

35 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 No. of Incidents Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 No. of Incidents 90 Incidents resulting in restraint in prone position at ELFT - C Chart UCL 59 per month 44% reduction per month 40 LCL UCL 134 per month Incidents resulting in Restraint at ELFT - C Chart per month 100 LCL % reduction 70

36 Percentage of Total Patients Monitored Improving physical health monitoring within an assertive outreach team 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Weight 51% 61% 73% 76% 79% 82% 83% 84% 89% BP 48% 59% 73% 77% 82% 84% 85% 86% 91% Bloodtest 40% 45% 63% 66% 70% 76% 78% 80% 84% ECG 39% 45% 55% 59% 65% 71% 73% 74% 77%

37 Number of days Improving clozapine results handling in City & Hackney Number of days taken from request for Serum level to receipt of results 50 Transitional Phase starts 45 UCL New clinic established LCL

38 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 No. of Referrals DNA / % ACCESS TO SERVICES COLLABORATIVE Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Average Waiting Time / Days December Baseline data 1 70 Average waiting time from referral to 1st face to face appt (Collaborative, 9/11 teams) - X-bar Chart UCL LCL No. of referrals received (Collaborative, 9/11 teams) - C Chart % of 1st face to face appt DNAs (Collaborative, 9/11 teams) - P Chart % UCL % 32.50% 1100 UCL % LCL 25.52% LCL 23% %

39 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14. Sat 07 Mar 15 Sat 14 Mar 15 Sat 21 Mar 15 Sat 28 Mar 15 Sat 04 Apr 15 Sat 11 Apr 15 Sat 18 Apr 15 Sat 25 Apr 15 Sat 02 May 15 Sat 09 May 15 Sat 16 May 15 Sat 23 May 15 Sat 30 May 15 Sat 06 Jun 15 Sat 13 Jun 15 Sat 20 Jun 15 Sat 27 Jun 15 Sat 04 Jul 15 Sat 11 Jul 15 Sat 18 Jul 15 Sat 25 Jul 15 Sat 01 Aug 15 Sat 08 Aug 15 Sat 15 Aug 15 Sat 22 Aug 15 Sat 29 Aug 15 Sat 05 Sep 15 Sat 12 Sep 15 Sat 19 Sep 15 Sat 26 Sep 15 Sat 03 Oct 15 Sat 10 Oct 15 Sat 17 Oct 15 Sat 24 Oct 15 Sat 31 Oct 15 Sat 07 Nov 15 Sat 14 Nov 15 Sat 21 Nov 15 Percent Reducing bed occupancy on an older adult functional ward in Newham = Baseline data 120% Ivory Ward Bed Occupancy: P Chart Target = 70% 100% 80% UCL LCL 88% 79% 60% 57% 40% 20% 0% Changes implemented: 1. Care pathway checklist 2. Daily discharge planning meeting/huddle 3. Digital display board for visual management of patient information/handover 4. Regular placement guidance from Senior Social Worker

40 Score Score (%) Staff experience and engagement Score 85 Staff able to contribute towards improvements at work 4.1 Staff Motivation at Work Staff job satisfaction Staff Survey - Overall Engagement Score ELFT Score National Average

41 Leading cultural transformation through QI

42 Building will Build a broad coalition for change Take time to bring people with you Shift decisionmaking to the edge Develop a compelling narrative Find some clear signals of change Use the power of stories Take every opportunity to celebrate

43 Building capability & capacity Be prepared to invest Train all levels and across disciplines Realign existing resources Stop lower value work

44 Alignment & integration Start at the top Create a support structure Build a learning system Ensure patients and carers are integral Ensure the context is ripe Line of sight from team to system goals

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