The healthcare improvement leaders essential toolkit

Transcription

1 The healthcare improvement leaders essential toolkit An ISQua webinar presented by Mark Jennings, Oxyjenn Consulting Ltd 30 th June 2017

2 Introduction Mark Jennings MBA. BSc. CEng. Managing Director Oxyjenn Consulting No interests to declare

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4 Webinar Objectives For participants to: 1. Understand the key approaches critical to making successful change 2. Be familiar with the essential tools in the improvement leaders toolkit 3. Be ready to apply the tools to your next project

5 Outline The four key approaches critical to making successful change and improvement in healthcare; Getting started: the three fundamental questions for all improvement initiatives Generating solutions: collaborative strategy development Selecting opportunities: prioritisation by impact and ease of implementation Knowing how you are doing: measuring progress and impact Followed by Questions and discussion

6 Who are you?

7 1.Getting Started

8 Three Fundamental Questions What are we trying to achieve? How will we know that a change is an improvement? What changes can we make that will result in an improvement?

9 Model for Improvement Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

10 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

11 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Establish MEASURES to determine if a specific change leads to improvement Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

12 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Establish MEASURES to determine if a specific change leads to improvement Select INTERVENTIONS most likely to result in improvement Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

13 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

14 If you don't know where you are going, any road will get you there

15 The Aim Statement Helps you focus on what your project needs to accomplish. It provides a specific, measurable statement of intent. The aim should be: S - Specific M - Measurable A Achieveable R - Relevant T Timebound E Engaging R - Recorded Clear and unambiguous, deliverable Observable outcomes of performance Quantity, Quality, Cost, Time Realistic within the capabilities and contraints Address a significant need You have a target date for completion Now is an opportune time to undertake the project Project will stimulate all concerned to action Written down for clarity, communication and review

16 Clear and measurable aims? Ensure timely completion of the assessment process All patients to have a complete medication list Manage the readmission rate Lower staff sickness rate Improve the care of frequently admitted patients Fewer medication errors Improve staff turnover Reduce patient falls Provision of timely and appropriate care for stroke patients

17 Some is not a number, soon is not a time How good? By when? Don Berwick IHI, Boston

18 Clear and measurable aims? Ensure timely completion of the assessment process All patients to have a complete medication list Manage the readmission rate Lower staff sickness rate Improve the care of frequently admitted patients Fewer medication errors Improve staff turnover Reduce patient falls Provision of timely and appropriate care for stroke patients How good? By when?

19 For your project Define a measurable aim Set AIMS that are measurable, timespecific, and apply to a defined population

20 The PDSA Cycle

21 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Establish MEASURES to determine if a specific change leads to improvement Select INTERVENTIONS most likely to result in improvement TEST the changes

22 Meeting rooms Design Design Design Design Opinion Approve Implement! Real world [Patient Safety First]

23 Meeting rooms Design Approve Observation data Test & refine Test & refine Test & refine Implement Real world [Patient Safety First]

24 Plan-Do-Study-Act disciplined framework ensures every part is done every time facilitates rapid prototyping and rolling out of new ideas

25 The usual approach

26 Change through small steps Change... with a clear purpose you can learn from (without fear of failure) which is less exhausting with fewer unintended consequences which builds engagement and optimism Always ask.. What is the smallest test of change you can try?

27 Plan-Do-Study-Act

28 Plan-Do-Study-Act

29 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Establish MEASURES to determine if a specific change leads to improvement Select INTERVENTIONS most likely to result in improvement TEST the changes

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31 2. Generating solutions

32 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Establish MEASURES to determine if a specific change leads to improvement Select INTERVENTIONS most likely to result in improvement Langley, G., Nolan, K., and Nolan, T., The Foundation of Improvement, Quality Progress, June 1994

33 Driver Diagrams: Collaborative solution development

34 Most solutions /interventions.

35 Driver Diagrams Secondary Driver Change Primary Driver Secondary Driver Change Aim: An improved system Secondary Driver Change Primary Driver Secondary Driver Secondary Driver Change Change Effect Drives Cause

36 Driver Diagram Weight loss example Substitute lower calorie foods Low fat meals Take packed lunch Buy only 1 sandwich 2 stone weight loss in 6/12 Reduce calories in Eat less Drink less alcohol Fruit for dessert Water bottle for work bag Put away the large glasses No pub weekdays Increase calories out Do sport Be more active during the day Gym work out 3 days Squash weekends Put cycling days in diary Cycling kit out night before Get rid of Oyster card Pedometer Take stairs

37 Urgent care Better population health Data focused plans Link to HWB priorities Proactive mental health care Medical team support on phone for paramedics 20 % REDUCTION IN ADMISSIONS FOR THE OVER 75s BY 2016 Reduce attendance at A&E Patient education Utilise alternative options Clinician education Best practice clinical management Make more use of paramedics Utilise SPA Work with third sector Social services input Optimise LTC management Extended scope paramedic roles All GP referrals to be triaged by SPA SPA inreach to A&E / MAU Reduce conversion to admission Increase efficiency / streamlining Rapid discharge options from A&E Non-home discharge Home discharge Increase community hospital beds Social worker on call in A&E Funding for volunteer home visitor training Effect Engagement meeting with local charities Cause

38 Generate Change Ideas Buy only 1 sandwich Gym work out 3 days Take stairs Low fat meals 2 stone weight loss in 6/12 No pub weekdays Cycling kit out night before Take packed lunch Squash weekends Put cycling days in diary Put away large wine glasses Fruit for dessert Pedometer Water bottle for work bag Get rid of Oyster card

39 Look for patterns Buy only 1 sandwich Gym work out 3 days Take stairs Low fat meals 2 stone weight loss in 6/12 No pub weekdays Cycling kit out night before Take packed lunch Squash weekends Put cycling days in diary Put away large wine glasses Fruit for dessert Pedometer Water bottle for work bag Get rid of Oyster card

40 Marshall a mass of ideas Take packed lunch Eat less Drink less alcohol Low fat meals Buy only 1 sandwich Water bottle for work bag No pub weekdays Substitute lower calorie foods Fruit for dessert Put away large wine glasses Put cycling days in diary 2 stone weight loss in 6/12 Cycling kit out night before Gym work out 3 days Do sport Be more active during the day Pedometer Take stairs Squash weekends Get rid of Oyster card

41 Marshall a mass of Substitute lower calorie foods Low fat meals Take packed lunch Buy only 1 sandwich ideas Reduce calories in Eat less Fruit for dessert Water bottle for work bag 2 stone weight loss in 6/12 Drink less alcohol Put away large wine glasses No pub weekdays Gym work out 3 days Increase calories out Do sport Squash weekends Put cycling days in diary Cycling kit out night before Get rid of Oyster card Be more active during the day Pedometer Take stairs

42 Prioritise

43 Surviving failure We tend to plan assuming this When all the evidence and our experience says it is like this

44 Survive failure: Try something else Buy only one sandwich Gym workout 3 days per week Take stairs

45 Consolidate success: Try something else Take packed lunch Buy only one sandwich Fruit for dessert Gym workout 3 days per week Take stairs

46 Driver Diagrams Secondary Driver Change Primary Driver Secondary Driver Change Aim: An improved system Secondary Driver Change Primary Driver Secondary Driver Secondary Driver Change Change Effect Drives Cause

47 Driver diagram Patient Safety First campaign M1 Measures bundle Aim Specific interventions

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50 Designing quality improvement initiatives: The Action Effect Method, a structured approach identifying and articulating programme theory NWL CLARHC

51 Verbal referrals That a person in xxxx experiences care that is led by them and supported by professionals who know each other and who operate within a culture where they connect people to the strengths and resources in their community. Give staff permission to get to know someone Positive risk taking Operational changes Coaching and mentoring People power Unified/compatible IT Person versus professional expertise in balance. Joint visits Active listening Someone takes overall responsibility care coordination Strengths based. What can an individual person do? Not want can t they do but what can they do. What are their strengths? Only act if doing so adds value to the person. Using human and professional skills to assess risk Leadership and management which supports positive risk taking Encourage individuals people/patient/client to take positive risk Broadening understanding of staff, for example time to Shadow others and that this time is valued by managers. Networking/educational events across organisations, similar to GP PLTs. Develop LAC role. Embed LAC in ICT teams but also accept that individual spends significant amounts of time in their community Create an ICT team identity and a team plan Develop one common tool to identify and measure what is important to the person 2gether to provide names and contact details of local staff to GCS, so that staff link and align to each of the existing 4 GCS ICT teams. One referral centre for locality for all referrals. Combine 2gether and GCS referral centres into one location. To include referral coordination. Overall aim would be to make the person safe and then assign to relevant staff (GCS or 2Gether) who do an assessment based on understand. Centre would receive referrals from people and professionals including GPs and local agencies. To include a share of the Adult Help Desk. Could deliver signposting element of Care Bill. Physically locate staff with ICT teams. The building could belong to either organisation. Not about changing the employer. Shared operational and peer supervision. Identify a lead professional for each person who has more than 1 professional involved in their care. Links to ICT case management pilot. Engagement and influencing Personal budgets and enhanced payments Engagement and influencing

52 AIM PRIMARY DRIVERS SECONDARY TERTIARY CHANGE IDEAS Aim Best Possible outcomes for mother and child Agreed pathways - midwifery led care [pre-conception to post-natal] Define roles & responsibilities Risk assessment at least each trimester and post partum Appropriate high risk pathways Enhanced roles for MSWs Case loading Risk assessment tool Review perinatal mental health practice & agree high risk pathways Outcomes Improve life outcomes: Pre term Still birth LBW Mortality Morbidity Safe and Effective Care Complex case management protocol Low risk pathways & out of hospital care High impact preconception advice Effefctive & timely screening (ante & post) Service Specs & SDIP Discuss with secondary/primary care Refine pre-conception & intervention training with staff Pharmacy referrals for booking Improve experience: Measures from experience surveys Reduce unwarranted variations in clinical behaviour Skilled & available workforce. Learning as system. Quality improvement skills Recruitment & Retention Glucose tolerance screening Workforce capacity review Safe reporting Safe Culture Best use of resources Top Quality Clinical Governance Effective staff supervision Develop culture of excellence CNST action plan Redefine quality metrics

53 Driver Diagram Checklist AIM ANY AIM GENERIC PRIMARY DRIVERS Workforce Demand management Collaboration and integration Alternative provision Information Premises Leadership and culture PROMPTS Workforce planning and development to ensure services delivered by an appropriately skilled workforce Methods to manage demand (including stratification and segmentation) have been considered System partners collaborate to improve care and integrate delivery Alternatives to conventional care delivery (including self-care) have been considered Accurate information available to support timely clinical decision-making Care delivered in premises that are appropriate, safe and efficient Local leadership and culture demonstrate support for aim and quality improvement

54 Driver Diagrams Benefits... build complex strategy immediate visual collaborative hypothesis avoid silver bullet thinking highlights overlooked ideas Different scenarios Helps generate change ideas 2. Marshall a mass of change ideas 3. Survive failure / the unexpected

55 For your project Draw a driver diagram EFFECT CAUSE Outcome Primary Drivers Secondary Drivers Process Changes S. Driver 1 Change 1 P. Driver Change 2 S. Driver 2 Aim: An improved system S. Driver 3 Change 3 P. Driver S. Driver 1 S. Driver 2

56 3. Selecting Opportunities

57 Prioritisation Matrix HIGH IMPACT HIGH LOW DO- ABILITY LOW

58 HIGH IMPACT HIGH LOW DO- ABILITY LOW

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61 IMPLEMENTATION Classifying potential interventions Integrated health and social care via a Care Trust Integrated intermediate care within general support for older people HARDER Acute visiting scheme in general practice Extended access hours intermediate care response teams Community Virtual wards IMPACT HIGHER Emergency care practitioners/paramedics on 999 ambulances Comprehensive ambulatory emergency care service for a wide range of emergency presentations Proactive outreach case management by district nurses and community matrons Focus on managing LoS and expediting discharge Care bundles /pathways for all emergency and elective care Improved clinical decisionmaking in A&E (use of senior staff earlier in the process ) Converting emergency admissions for particular presentations to day cases EASIER Integrated urgent care in general practice GPs in A&E LOWER 2011 Oxyjenn Consulting D R A F T

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63 4. Knowing how you are doing

64 We re pressed for time, so we ll be jumping to conclusions

65 Meeting rooms Design Approve Observation data Test & refine Test & refine Test & refine Implement Real world [Patient Safety First]

66 Meeting rooms Design Approve Measurement Test & refine Test & refine Test & refine Implement Real world [Patient Safety First]

67 Dimensions of measurement Why measure? What to measure? How to use measures?

68 Why measure? The three purposes of measurement Research eg A-B comparison, average, huge dataset Judgement eg one-to-many benchmarking comparison, average, large dataset Improvement eg continual analysis of single changing process over time

69 Mindsets Judgement Improvement Research

70 Measurement mindsets Research Judgement Improvement Goal New knowledge (not its applicability) Comparison Reward / punishment Spur for change Process understanding Evaluating a change Hypothesis Fixed None Multiple and flexible Measures Many Very few Few Time period Long, past Long/medium, past Short, current Sample Large Large Small Confounder s Measure or control Describe and try to measure Consider but rarely measured Risks in improvemen t settings Ignores time based variation Over-engineers data collection Ignores time based variation Over-reaction to natural variation Incorrectly perceived as inferior statistics Based on L Solberg, G Mosser and S McDonald (1997) The Three Faces of Performance Measurement: Improvement, Accountability and Research, Journal on Quality Improvement, 23 (3):

71 Measures plotted on driver diagram Outcome Primary Drivers Secondary Drivers Ideas for Process Changes drives Calories In Daily calorie count drives drives drives Limit daily intake Avg cal/day % of Substitute opportunities used low calorie foods Track Calories Running calorie total Plan Meals offplan/week AIM: A New ME! Weight BMI Body Fat Waist size drives Exercise calorie count Calories Out drives drives Avoid alcohol Exercise Avg drinks/ week Drink H2O Not Soda Sodas/ week Work out 5 days Days between workouts drives Fidgiting Bike to work Percent of days on bike Hacky Sack in office Etc...

72 What to measure

73 What to measure? Structure Process Outcome The environment in which care occurs What care is delivered, and how The impact on patients and the population Outcomes remain the ultimate validators of the effectiveness and quality of medical care but they must be used with discrimination Avedis Donabedian

74 What to measure? Structure Process Outcome eg Structure indicators patients treated on a specialist stroke unit attributes relating to clinicians (such as certification, training) staffing ratios surgical volumes access to equipment eg, MRI scanners.

75 What to measure? Structure Process Outcome Pros Pros Expedient // inexpensive Data Data often often available available Efficient one indicator may relate to Efficient several outcomes one indicator may relate to several outcomes Often evidence-based Often evidence-based Cons Cons Limited number of measures, especially for ambulatory care Not always actionable eg, a small hospital cannot readily become a high-volume centre Work better as markers of aggregate performance than performance of individual providers Less appealing to many than outcome indicators

76 What to measure? Structure Process Outcome eg Process indicators antenatal assessment <13 weeks physical checks in people with serious mental illness structured education for people with diabetes people with stroke reviewed <6 months of leaving hospital psychological support after stroke

77 What to measure? Structure Process Outcome Pros Pros Cons Cons Most evidence-based indicators are Often too specific, narrow process related Direct measure of quality Links with outcomes variable/unclear Reflect care that patients receive Can become tick box exercise Easily measured, data collection easier Potentially subject to manipulation Easy to interpret May have little appeal for patients Not subject to time lags Don t require risk adjustment Actionable, therefore useful for quality improvement, performance

78 What to measure? Structure Process Outcome eg Outcome indicators recovery following talking therapies under 75 mortality rate from cancer hospital admissions for ambulatory care-sensitive conditions mortality within 30 days of hospital admission for stroke emergency re-admissions within 30 days of discharge from hospital health-related quality of life for people with long-term conditions patient experience of GP out-of-hours services Patient Reported Outcome Measures

79 What to measure? Structure Process Outcome Pros Pros Cons Cons Face validity Link to care quality variable / unclear modern medicine can t cure everything Reflect all processes of care Affected by factors unrelated to care Effective where close causal link exists quality between Effective intervention where close & causal outcome link exists Attribution often difficult/uncertain Measurement between intervention and feedback & outcome can drive improvement Measurement and feedback can drive Measurement challenges: - risk improvement adjustment - good-quality clinical data - Not easily manipulated outcomes often low-frequency events Effectively Not easily manipulated applied in surgery eg, Potential for risk avoidance cardiac Effectively surgery applied in surgery eg, Limited use in primary, medical, cardiac surgery ambulatory care

80 Explaining outcomes Structure Process Outcome Category of explanation Differences in patient types Impact of external factors Measurement challenges Chance Sources of variation Patient characteristics eg, comorbidity, severity, socio-economic status eg quality of primary, community, ambulance care, local availability of hospices Ascertaining risk factors, availability of data, method of analysis eg, method of risk adjustment Random variation, influenced by

81 What to measure? Structure Process Outcome Intermediate outcomes a common solution properties of both process & outcome but be careful to acknowledge it s not the ultimate outcome

82 INPUTS Outcome OUTPUTS Measure What to measure? Is it working? EXTERNAL FACTORS Is it in place? Is it being done? Process Measure HUMAN FACTORS INTERNAL PROCESSES & PROCECEDURES Structure Measure HUMAN FACTORS

83 Metrics for different audiences Focus on outcome Board Highest level outcome measures Service managers Higher level outcome measures Project managers Relevant process + outcome measures Focus on process Frontline staff Relevant process + outcome measures

84 Balancing measures

85 INPUTS Outcome OUTPUTS Measure(s) What to measure? Is it working? EXTERNAL FACTORS Is it in place? Is it being done? HUMAN Process FACTORS Measure(s) INTERNAL PROCESSES & PROCECEDURES Structur e Measure (s) HUMAN FACTORS Unintended consequences? Balancing Measure(s)

86 How to use measures

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88 How do you look at your data?

89 How do you look at your data?

90 The Problem Aggregated data presented in tabular formats or with summary statistics, will not help you measure the impact of improvement efforts. Aggregated data can only lead to judgment, not to improvement.

91 Wait Time (min.) Waiting time results Avg Before Change 35 Avg After Change

92 date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Cycle Time (min.) Wait Time (min.) date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Cycle Time (min.) date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Cycle Time (min.) Waiting time results 0 Change Made Unit Avg Avg After Before Change Change Change Made Change Made Unit 2 Unit 3

93 Why Time Is Important for Measurement Aggregate measures alone do not lead to predictions about future performance or insights to explain past variations Displaying data over time allows us to make informed predictions, and thus manage effectively Richard Scoville & I.H.I.

94 Enumerative Dynamic

95 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 % reconciled Run Chart Pharmacy included Protocol introduced Letter from Clinical Director Pre op briefings % surgical patients receiving Prophylactic Antibiotics

96 Model for Improvement Set AIMS that are measurable, timespecific, and apply to a defined population Establish MEASURES to determine if a specific change leads to improvement Select INTERVENTIONS most likely to result in improvement TEST the changes

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98 Questions and Discussion

99 Mark Jennings +44 (0)