Step by step measurement guide

Step by step measurement guide The guide has been produced under a creative commons license please use the symbols shown for guidance if you wish to use or adapt the material This edited presentation has been made available to support personal learning. Many of the images in this presentation have been purchased for this purpose. The presentation has been created by the author and can be downloaded for personal use. The correct citation for this document is: Davey N.J., 2015, Step-by-step measurement - with examples from handover & transfers of care, Sign up to Safety Campaign Webinar series Nicola@qualityimprovementclinic.com Copyright 2015: Quality Improvement Clinic

Handover & transfers of care Step-by step measurement guide For people who want to measure improvement Author: Nicola Davey August 2015 Delayed discharges Avoidable harm Frustrated staff Complaints Home on time Harm free care Job satisfaction A great reputation

Model for Improvement How will we know if a change is an improvement? Reference The Model for Improvement. Langley, Nolan, Nolan, Norman & Provost. The Improvement Guide, Josse Bass, 1996 Copyright 2015: Quality Improvement Clinic

How do we know our change efforts are delivering improvements? 7 steps to measurement http://www.youtube.com/watch?v=za1o77janbw

Step 1 Decide AIM Steps 2 to 3 - Choose & define measures Steps 4 to 7 - Collect, analyse, review Structured transfer of care/handover in team/service right each time by Have you involved your team? Did you included a patient in your team? Do you KNOW what matters to them? A good handover. ensures changes in clinical teams are not detrimental to quality of care improves communications between all in care team, including patients and carers identifies unstable/unwell patients, for optimal, clear and unambiguous management improves efficiency of patient management by clear baton-passing improves patient experience and confidence Offers teaching/learning opportunities for trainees to observe appropriate role models Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Step 1 Decide AIM Structured transfer of care/handover in team/service right each time by Have you involved your team? Did you included a patient in your team? Do you KNOW what matters to them? Steps 2 to 3 - Choose & define measures Success = Observed handovers Right people Right place Right time Right information Right record Right action Right patient outcome Steps 4 to 7 - Collect, analyse, review A good handover. ensures changes in clinical teams are not detrimental to quality of care improves communications between all in care team, including patients and carers identifies unstable/unwell patients, for optimal, clear and unambiguous management improves efficiency of patient management by clear baton-passing improves patient experience and confidence Offers teaching/learning opportunities for trainees to observe appropriate role models Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Step 1 Decide AIM Structured transfer of care/handover in team/service right each time by Have you involved your team? Did you included a patient in your team? Do you KNOW what matters to them? Steps 2 to 3 - Choose & define measures Success = Observed handovers Right people Right place Right time Right information Right record Right action Right patient outcome Steps 4 to 7 - Collect, analyse, review Plot results e.g. observe 5 transfers/week 4 weeks to generate baseline (20 data points) Continue collecting to maintain performance and explore reasons if not * This will tell you whether the changes you have made have improved transfer of care/ handover in YOUR service A good handover. ensures changes in clinical teams are not detrimental to quality of care improves communications between all in care team, including patients and carers identifies unstable/unwell patients, for optimal, clear and unambiguous management improves efficiency of patient management by clear baton-passing improves patient experience and confidence Offers teaching/learning opportunities for trainees to observe appropriate role models Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Preparedness to deliver care.. Staff survey - Level of preparedness to deliver care (1 = not prepared, 5 = prepared) 5 Staff Survey Results Median George Eliot Hospital 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Copyright 2015: Quality Improvement Clinic

% patients discharged by 12,00 % Patients discharged by 12.00 30 25 20 15 10 5 0 Baseline Intervention week 30 25 Patients discharged by 12.00 UCL 27.705 20 15 CL 15.786 10 5 0 LCL 3.866 Active Intervention 1 2 3 4 5 6 7 8 9 10 11 12 13 14 s Copyright 2015: Quality Improvement Clinic

% patinets discharged by 12.00 30 25 Patients discharged by 12.00 UCL 26.965 20 15 CL 15.250 10 5 0 LCL 3.535 Active Intervention 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 s Copyright 2015: Quality Improvement Clinic

Step 1 Decide AIM Structured transfer of care/handover in team/service right each time by Have you involved your team? Did you included a patient in your team? Do you KNOW what matters to them? Steps 2 to 3 - Choose & define measures Success = Observed handovers Right people Right place Right time Right information Right record Right action Right patient outcome Steps 4 to 7 - Collect, analyse, review Plot results e.g. observe 5 transfers/week 4 weeks to generate baseline (20 data points) Continue collecting to maintain performance and explore reasons if not * This will tell you whether the changes you have made have improved transfer of care/ handover in YOUR service A good handover. ensures changes in clinical teams are not detrimental to quality of care improves communications between all in care team, including patients and carers identifies unstable/unwell patients, for optimal, clear and unambiguous management improves efficiency of patient management by clear baton-passing improves patient experience and confidence Offers teaching/learning opportunities for trainees to observe appropriate role models Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Complexity and Reliability Source: Robert Lloyd diagnosis Correct antibiotic chosen Correct prescription available Antibiotic given within right time scale If the reliability of each step is 90% then the overall reliability for the 4 steps together is only 65.61% (.90^4=.6561) Aim: 90% compliance with SCIP-Inf- 1a: Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision (4 step process) Probability of on-time successful completion at each step Steps 90.00% 99.00% 99.90% 99.99% 99.999% 1 90.00% 99.00% 99.90% 99.99% 99.999% 2 81.00% 98.01% 99.80% 99.98% 99.998% 4 65.61% 96.06% 99.60% 99.96% 99.996% 8 43.05% 92.27% 99.20% 99.92% 99.992% 16 18.53% 85.15% 98.41% 99.84% 99.984% 32 3.43% 72.50% 96.85% 99.68% 99.968% 64 0.12% 52.56% 93.80% 99.36% 99.936% 128 0.00% 27.63% 87.98% 98.73% 99.872% How does the complexity of your process affect reliability? Copyright 2015: Quality Improvement Clinic

Choose your 1st improvement focus* Steps 2 to 3 - Choose & define measures Steps 4 to 7 - Collect, analyse, review Right Information Standardised protocol correctly use the right process, capture and pass on right information in.. team/service every time by * Example from NSW [New South Wales] Health Implementation Toolkit, Standard Key Principles for Clinical Handover http://www.archi.net.au/resources/safety/ clinical/nsw-handover/standard Is time set aside for multiprofessional handover in current working practice? Are checklists in place for handover process? Is standardised proforma used for communicating handover? Is handover process included in training/induction? Any serious incidents attributed, wholly/partly, to poor communication/handover? Is system of handover audited? Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Choose your 1st improvement focus* Steps 2 to 3 - Choose & define measures Steps 4 to 7 - Collect, analyse, review Right Information Standardised protocol correctly use the right process, capture and pass on right information in.. team/service every time by Success = Observed handovers Used right template Communicated effectively Recorded critical information in notes * Example from NSW [New South Wales] Health Implementation Toolkit, Standard Key Principles for Clinical Handover http://www.archi.net.au/resources/safety/ clinical/nsw-handover/standard Is time set aside for multiprofessional handover in current working practice? Are checklists in place for handover process? Is standardised proforma used for communicating handover? Is handover process included in training/induction? Any serious incidents attributed, wholly/partly, to poor communication/handover? Is system of handover audited? Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Number of times standard format followed George Eliot Hospital Number of times standard format followed Median 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Copyright 2015: Quality Improvement Clinic

Choose your 1st improvement focus* Steps 2 to 3 - Choose & define measures Steps 4 to 7 - Collect, analyse, review Right Information Standardised protocol correctly use the right process, capture and pass on right information in.. team/service every time by Success = Observed handovers Used right template Communicated effectively Recorded critical information in notes * Example from NSW [New South Wales] Health Implementation Toolkit, Standard Key Principles for Clinical Handover http://www.archi.net.au/resources/safety/ clinical/nsw-handover/standard Is time set aside for multiprofessional handover in current working practice? Are checklists in place for handover process? Is standardised proforma used for communicating handover? Is handover process included in training/induction? Any serious incidents attributed, wholly/partly, to poor communication/handover? Is system of handover audited? Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Choose your 1st improvement focus* Steps 2 to 3 - Choose & define measures Steps 4 to 7 - Collect, analyse, review Right Information Standardised protocol correctly use the right process, capture and pass on right information in.. team/service every time by Success = Observed handovers Used right template Communicated effectively Recorded critical information in notes Plot results e.g. 5 transfers/week 4 weeks to generate baseline (20 data points) Continue collecting until small scale tests of change result in sustained improvement i.e. a reliable handover every time * Example from NSW [New South Wales] Health Implementation Toolkit, Standard Key Principles for Clinical Handover http://www.archi.net.au/resources/safety/ clinical/nsw-handover/standard Is time set aside for multiprofessional handover in current working practice? Are checklists in place for handover process? Is standardised proforma used for communicating handover? Is handover process included in training/induction? Any serious incidents attributed, wholly/partly, to poor communication/handover? Is system of handover audited? Adapted from the Royal College of Physicians, Acute Care Toolkit: 1 Handover (2011)

Small scale tests of change (PDSA) (or Eating the elephant one bite at a time! ) PLAN DO STUDY ACT Choose your 1 st change intervention Standard Choose & define your measure/s Success = Team consensus on must have information items Collect Dot voting 1 For all items listed by team Analyse & review Feedback results i.e. All items for inclusion Examples Include all items voted for in initial form design information template to capture right information.. team/service every time by 1 See page 9

Small scale tests of change (PDSA) (or Eating the elephant one bite at a time! ) PLAN DO STUDY ACT Choose your 1 st change intervention Choose & define your measure/s Collect Analyse & review Examples Standard information template to capture right information.. team/service every time by 1 See page 9 Success = No. of form design features that meet industry standard test for usability Success = Time taken to complete No. of critical points captured i.e. accuracy, completeness Apply tests (established industry standard) to information template/ form Undertake user testing Staff in side room complete template for case scenario/s Analyse results of tests and make recommendations for improvement Capture results of observations 5 staff (different experience levels) Make content & design changes in line with recommendations Undertake small scale tests 1,3,5 etc. Use simulation to reduce risk in early testing. Extend tests to small clinical area and then more conditions (e.g. at night, at weekend, with agency staff) Repeat amend & test cycle >80% reliability in use

Small scale tests of change (PDSA) (or Eating the elephant one bite at a time! ) PLAN DO STUDY ACT Choose your 2 nd change intervention Choose & define your measure/s Collect Analyse & review Examples Use of Structured communication tool to communicate information and escalate concerns effectively in.. team/service every time by 1 See page 9 Success = No. of staff attending training OR e-learning OR team brief Success = % handovers observed where SBAR 1 used effectively* *Define in advance Numbers trained in use of SBAR 1 No. done correctly Sample = 1 shift change/ ward/ team. NB vary sampling times Observed barriers Plot results e.g. no of staff trained (cumulative) Plot results e.g. 5 transfers/week 4 weeks to generate baseline (20 data points) Continue collecting until small scale tests of change result in sustained improvement Explore ways to overcome barriers Behaviour change is your ultimate goal! Revise training, SBAR prompts, feedback etc. to overcome barriers and achieve >80% reliability in communication and escalation

Small scale tests of change (PDSA) (or Eating the elephant one bite at a time! ) PLAN DO STUDY ACT Choose your 3 rd change intervention Documented transfer of care Accessible to. every time by Choose & define your measure/s Success = No. of transfers containing complete* documentation * Define in advance Collect data Complete and sign handover form OR Computer entry completed Sample = 1 shift change/ ward/ Team NB vary sampling times Observed barriers Analyse & review Plot results e.g. 5 transfers/week 4 weeks to generate baseline (20 data points) Continue collecting until small scale tests of change result in sustained improvement Explore ways to overcome barriers2 Examples Safety feature: Information, there when you need it! Include (file) handover sheet with other routinely accessed record (nursing or clinical record) Remove barriers to computer data access Create handover template for computer that doubles as record Repeat test cycle >80% reliability in storage and retrieval

Choose your 2 nd improvement focus* Right People Leader is always known to all at handover Relevant staff are always present and able to participate in every handover in.. Team What other change is needed in your local practice? What change interventions can you test? * Checklist adapted from the NSW [New South Wales] Health Implementation Toolkit, Standard Key Principles for Clinical Handover http://www.archi.net.au/resources/safety/clinical/nswhandover/standard

Useful links Measurement Webex, Nicola Davey, Sign Up to Safety Campaign http://tinyurl.com/su2smeasure Safe Communication: Design, implement and measure: A guide to improving transfers of care and handover http://www.england.nhs.uk/signuptosafety/sipresources/ 7 Steps to measurement, Mike Davidge, NHS Institute for Innovation and Improvement http://www.youtube.com/watch?v=za1o77janbw SBAR resources www.institute.nhs.uk/sbar Royal College of Physicians Acute Care Toolkit 1: Handover https://www.rcplondon.ac.uk/resources/acute-care-toolkit-1-handover IMPLEMENTATION TOOLKIT Standard Key Principles for Clinical Handover, NSW Health, 2009 http://www.aci.health.nsw.gov.au/resources/acutecare/safe_clinical_handover/implementation-toolkit.pdf Shutterstock Images

Films The Model for Improvement (2.5 mins) https://www.youtube.com/watch?v=scyghxtioiy Run Charts Part 1 (6.22 mins) https://www.youtube.com/watch?v=8e38rcu8-ua Part 2 (6.22 mins ) https://www.youtube.com/watch?v=8e38rcu8-ua Developing measures for your safety improvement plans http://www.england.nhs.uk/signuptosafety/webinars/ 17 th December 2014 Re-ACT Talks: Designs, Scores and Systems: Making it Easier to do the Right Thing https://www.youtube.com/watch?v=cgmuqdediou Copyright 2015: Quality Improvement Clinic

Other resources The Health Foundation Publications http://www.health.org.uk/publication/framework-measuring-and-monitoringsafety NHS Institute for Innovation and Improvement Quality and Service Improvement Tools www.institute.nhs.uk/qualitytools Statistical Process Control (SPC) charts www.institute.nhs.uk/spc Copyright 2015: Quality Improvement Clinic