Aneurin Bevan Continuous Improvement

Aneurin Bevan Continuous Improvement Creating a Health Board Centre for Quality Improvement 1. Introduction The purpose of this report is to outline a proposal for the creation of the ABCi Centre for Improvement. The Board is requested to note the report and support the next steps identified within this report. Financial Assessment and link to Financial Recovery Plan Risk Assessment Any additional financial implications are being assessed. Implementation of this strategy will not pose any risk to the Health Board and will assist in the Health Board s mitigation and response to existing risk areas Annual Quality Framework This would support the delivery of the Annual Quality Framework Standards for Health Services Wales Equality Impact Assessment Child Impact Assessment This proposal would support the range of Standards for Health Services Wales Equality Impact Assessment will be undertaken. The Impact on Children and Young People will be considered as required. Page 1 of 18

1.1 The need to improve quality within limited resources Healthcare providers in Wales, and across the world, face the same challenge; to deliver services of increasing quality within limited budgets. Together for Health sets out the Welsh Government s vision for the NHS in 2016: Health will be better for everyone Access and patient experience will be better and Better services, safety and quality will improve health outcomes The 8 action areas for delivery are: 1. Improving health as well as treating sickness 2. One system for health 3. Hospitals for the 21st century as part of a well designed, fully integrated network of care 4. Aiming at excellence everywhere 5. Absolute transparency on performance 6. A new partnership with the public 7. Making every penny count 8. We will help our staff to be the best This quality improvement must be delivered within what is essentially a flat cash financial settlement for the NHS in Wales for the foreseeable future. 1.2 Quality is a key business strategy for NHS Wales Together for Health contains a commitment to ensure that quality improvement processes in Wales match best in class, and training staff in continuous improvement is critical to the approach adopted by the Welsh Government. This has been described as the recognition that everyone has two jobs: to do their work, and continuously improve the healthcare system they work within The requirement for quality improvement is reinforced by two further papers from Welsh Government which compliment Together for Health. Achieving Excellence, the Quality Delivery Plan for the NHS in Wales, contains a requirement for Health Boards and Trusts to train 25 per cent of their directly employed and contractor workforce in 1000 Lives Plus quality improvement methodology by the end of March 2014. Working Differently Working Together, the Workforce and Organisational Development framework for the NHS in Wales, directs leaders and managers to redesign services Page 2 of 18

and pathways using 1000 Lives Plus methodology, and to ensure that all clinical staff are engaged in 1000 Lives Plus and trained in improvement methodology. 1.3 Local challenges The Aneurin Bevan Health Board Vision is: Working with you for a healthier community Caring for you when you need us Aiming for excellence in all we do Our purpose always to: Put the patient first Continuously improve with every action The key performance challenges to the Health Board over the coming year and beyond are: Improvements in Unscheduled Care so there are no delays in A&E departments Improving Scheduled Care performance to best in class to achieve access targets with minimal reliance on waiting list initiatives Improving the performance of Frailty care so frail patients are kept away from hospital and only stay for a minimum period when admission is required Further reductions in Healthcare Acquired Infections and Pressure Ulcers 1.4 2012-13 Annual Plan This year s Annual Plan sets out the Priority Change Programmes the Health Board has identified locally to respond to these challenges: Saving 100,000 bed days Harnessing opportunities in commissioning Reconfiguring services inline with Clinical Futures Delivering access through team effectiveness Making the best use of medicines A continuous improvement approach will enable an effective and sustainable response to these challenges, and the Priority Change Programmes described in the Annual Plan will depend upon a clear improvement approach allied to clear accountability for their delivery. A quality improvement approach will be particularly Page 3 of 18

important in the delivery of the 100,000 Bed Days and the Delivering Access through Team Effectiveness programmes. The Annual Plan outlines the intention of the Health Board to create a Centre for Continuous Improvement to optimise training in, and delivery of, continuous quality improvement across the Health Board. This paper outlines plans to create the ABCi Centre for Continuous Improvement in the Health Board, mainly by amalgamating existing improvement resources. A Questions and Answers section is included as an appendix (appendix 1) to give a clear idea of how the centre will work. 2. Existing support for quality improvement in ABHB Support to clinical teams in the Health Board for quality improvement work currently comes from a number of sources: 2.1 1000 Lives Plus Aneurin Bevan Health Board and its predecessor organisations have been working in a structured way using the Model for Improvement (MFI) devised by the Institute for Healthcare Improvement (IHI), since being accepted onto the Safer Patients Initiative 2 in 2006. Since this time, the has organisation participated fully in the 1000 Lives Campaign and 1000 Lives Plus. Quality improvement work is in place across the whole of the organisation in acute, community, primary care and nursing homes. The 1000 Lives Plus programme is being implemented through a series of mini-collaboratives, and the organisation continues to implement and spread the interventions from the previous 1000 Lives campaign. Implementation of the different interventions has been supported by training, particularly on PDSA cycles and small tests of change, and measurement and reliability. There is now a cohort of staff through out the organisation who are skilled and experienced in using this methodology, providing a strong foundation for a quality transformation. The use of Model for Improvement tools has been pivotal in achieving impressive improvements in Health Board performance, including dramatic improvements in stroke services and large falls in the incidence of healthcare acquired infections, and the Transforming Care programme provides a foundation for quality improvement at ward level. Page 4 of 18

2.2 Service Improvement The Health Board has a comprehensive programme of service improvement work managed locally within the Divisions, with support from a corporate Service Improvement Team within the Planning and Operations, which includes the Head of Service Planning and Improvement and five supporting team members. Specific service improvements by division are itemised in the Aneurin Bevan Annual Plan, and are aimed at: increasing the range of services provided in communities through primary, community and mental health services using Setting the Direction as a model framework (Level 1); developing a network of Local General Hospitals providing routine hospital services including emergency care, day case and short stay surgery, outpatients, diagnostic and integrated care, together with mental health services (Level 2); developing a single Specialist and Critical Care Centre (SCCC) providing specialist and critical care services that cannot be provided on multiple sites based on sustainability, clinical effectiveness, patient safety and affordability (Level 3); developing specialist mental health services (Level 3). Scoping work is currently underway to establish a database of staff across the organisation with Service Improvement qualifications such as NVQs in Lean and Six Sigma green and black belts. 2.3 Organisational Development Strategy The OD Strategy contains a number of important elements that contribute towards the continuous improvement transformation: Team Based Working. This programme is recognised as the cornerstone to develop effective working at all levels of the Health Board and is one of the mechanisms by which quality improvement can be operationalised. The implementation plan is currently focusing on teams with high levels of sickness absence to ensure greatest benefit. Personal Appraisal and Development Reviews (PADR) and the Knowledge & Skills Framework. The NHS Knowledge and Skills Framework (KSF) is a tool for describing the knowledge and skills staff need to apply at work in order to deliver high quality services. It is embedded in an annual system of PADR for staff and ensures that personal development is linked to organisational objectives, priorities and outcomes. It applies to all staff covered by Agenda for Page 5 of 18

Change contracts but Medical staff also have a system of annual appraisals and personal development reviews linked to (but separate from) their job plans Leadership for Quality and Improvement (LQI). This is a framework for delivery and the strength of this programme is that it combines leadership and service improvement throughout. The focus is on improvement in quality, and reduction of waste and variation and is based on the concept of learning while delivering a key service improvement outcome. It has been developed by NLIAH to ensure that middle managers have the combined leadership and service improvement skills required to deliver organisational plans and objectives. Coaching for Improvement. In addition the Health Board is developing a Coaching strategy that will embed behaviours and an approach that will support a continuous improvement culture (see paragraph 4.2). 2.4 Service Line Reporting and Clinical Performance Both the national and our local Five Year Strategic, Workforce and Financial Plans, include as one of the fourteen high value opportunities the need to establish service line management and patient level costing, as one key way in which we engage front line staff in the sustainability agenda. The Financial Performance and Business Intelligence team are leading on the delivery of this for the Health Board, specifically through leading elements of work in systems performance and financial sustainability, to help the organisation deliver on service transformation, recognised as a core requirement in delivering its overall ambitions. A key enabler to an improvement culture is the skill of specialists who can present complex analyses in an easily understood format and the willingness and ability of clinical teams to use the information to understand the problem and take forward the solution. It is important that the measures are presented within an appropriate time frame to the clinical issue, this means that the organisation needs to prepare for real time systems. Some information is available to the health board via CHKS, but some important measures of quality are either hard to derive, or currently unmeasured. Page 6 of 18

3. Moving to Best in Class for quality improvement The current delivery of improvement skills and capability within the Health Board is fragmented and its organisational penetration is inconsistent. Despite this there have been conspicuous successes in the application of improvement methodology. There have been dramatic, and sustained, improvements in the rate of healthcare associated infections and in stroke care through the 1000 Lives Plus programme in the recent past, and a quality improvement approach has resulted in significant improvements in the community care of patients with Chronic Airways Disease. In all these instances improvement methodology has been allied to a clear accountability framework. 3.1 Identifying Best in Class for quality improvement Other healthcare organisations, in the UK and abroad, have adopted quality improvement as their business strategy, and have developed a structured approach to supporting continuous quality improvement. Examples of best in class in this regard, visited by members of the Health Board, are the Qulturum, which has been in operation over the past ten years in Jönköping County, Sweden, and the Tayside Centre for Organisational Effectiveness in Scotland. The common features of this approach are: A consistent approach to improvement. Usually centred on the IHI s Model for Improvement, but embracing other improvement methodologies such as Lean and Six Sigma where necessary. Adoption of the Institute of Medicine s 6 quality domains: Safe, Effective, Patient-centered, Timely, Efficient, Equitable. The patient placed at the centre. Developing care systems so that they maximise value to the service user exemplified by the Esther Project in Jönköping. A care pathways approach cutting across organisational structures is commonly employed. Structured support for care teams to improve. Strong commitment to learning as the key to innovation and improvement with a team coaching approach (Paul Batalden s work on microsystems is widely quoted) and training in improvement methodology with a special emphasis on measurement approaches. The care team will include all care givers, including staff working in the Facilities Division. A structured programme of training in improvement methodology. So that a core of staff have advanced knowledge of improvement methodology and how to apply it, and all staff have some familiarity with this. A well developed Page 7 of 18

example of this is the Advanced Training Programme run by Intermountain Healthcare. Collection of, and access to, a database of evidence for improvement. It is important to know what works, both locally, and at Best in Class sites internationally, so that this can be shared freely with all care teams. 3.2 Creating an ABHB Centre for Improvement. To work most effectively, existing sources of support for quality improvement will be integrated into a single Centre for Improvement in the Health Board. Some preliminary work has taken place with the communications team, to create the Aneurin Bevan Continuous Improvement (ABCi) title and logo: The ABCi Centre for Improvement will work across the whole patient pathway, from public health to hospital care, to: Bring experts from different disciplines and professions together so that all staff receive targeted, co-ordinated QI support Create space for clinical teams to think innovatively, ensuring that healthcare technology is applied to improve outcomes Put patients at the centre of all it does, and foster expertise in improving patient experience across the Health Board. Ensure improvement activities follow a common approach, based on the Model for Improvement, and promoting excellence in measurement for improvement, but allowing the flexible use of other QI approaches (e.g. Lean, 6 sigma) Teach QI at Basic, Expert and Leadership level across the Health Board Store and share knowledge to promote an all teach, all learn approach, creating a shared visual presence for improvement activities and their associated benefits Work closely with Research and Development Explore opportunities to market Quality Improvement expertise beyond the Health Board ABCi will initially have an identity on the Health Board intranet site, and will be developed as a physical centre for clinical teams to come to meet and learn. In addition, specific locations will be developed across Health Board sites to facilitate local continuous improvement events. Page 8 of 18

The centre will be populated by existing staff engaged in quality improvement work across the Health Board to form an initial core of 20 or so staff who to support continuous improvement. Initially, some staff will be ABCi Associates, working full time within the centre. It is envisaged that these staff will already be undertaking improvement work for the majority of their time (e.g 1000 Lives team) and this will involved a straightforward transfer of management accountability at no additional cost. Some will be Affiliates, and this group will be broadly split into two; Firstly those whose existing job plan will include work that will be co-ordinated by the centre (e.g. the OD team) and who will have that proportion of their work managed by the Centre (no additional cost but an appropriate performance management infrastructure will be needed); Secondly and at a slightly later stage - those staff who have some expertise in improvement methodology or the supporting OD capability building, (e.g. those involved on the Transforming care projects) and who can contribute to the work of the Centre on an agreed basis e.g. by project or for a set number of days per year. For these latter staff further work will need to be done in recognising their existing commitments and then assessing what the organisational return on investment would be if they were to spend time focussing on improvement work. In addition to a core team of full time staff the ABCi faculty for improvement will support Improvement Experts embedded in clinical teams, and will oversee a programme of training to ensure that all Health Board staff have some familiarity with continuous improvement methodology. Figure 1 (below) shows a schematic for this. Aneurin Bevan Health Board Corporate Teams ABCI Director Affiliates Programme Manager Associates Care Pathways,Continuous Improvement Support Improvement experts Figure 1 Unscheduled Care Division Scheduled Care Division Facilities Division Family & Therapies Division Public Health Division Mental Health & LD Division Community Care Division Primary Care Division Page 9 of 18

3.3 Core Improvement Methodology The core ABCi improvement tool will be the IHI Model for Improvement, which is based on Edwards Deming s System of Profound Knowledge. This requires clinical teams to be clear about their objectives and to put in place a process of measurement that will allow them to judge whether the changes they make to the system of care they operate have resulted in improvement (figure 2). Figure 2 The Model for Improvement Clinical teams will enter an iterative process so that they base future improvement actions on the observed results of previous actions (figure 3). Figure 3 The 7 steps to improvement Page 10 of 18

3.4 Communication Plan A communications plan for continuous improvement will be developed for the Health Board to include: A continuous improvement intranet site, including service improvement and 1000 Lives Plus activities Professional branding and marketing of improvement activities (based on the model adopted by the 1000 Lives Plus campaign) A continuous improvement Learning Event for Health Board staff, held every 6 months, enabling a greater number of staff to become involved in quality improvement Continuous Improvement notice boards to be set up around the main Health Board hospitals in high footfall areas A Continuous Improvement Newsletter to be published regularly Celebration events for notable success in quality improvement Use of social media 3.5 Developing an Improvement Culture There is an existing commitment in the Aneurin Bevan Health Board to an open, transparent culture that promotes learning and safety. This is highly aligned to the development of a pervasive culture of quality improvement so that continuously improving becomes the way we do things around here. Additionally, most advanced approaches to continuous improvement make extensive use of coaching techniques the Director of the Jönköping Qulturum was previously the Swedish national basketball coach. Coaching is widely recognised as a method of developing employees and specifically managers to enhance organisational performance and has been shown to be one of the most effective ways of unlocking potential and creating an empowering environment in which to work. Coaching is a low cost, low risk tool to effectively manage performance by developing the confidence and competence of individuals. Coaching typically delivers sustainable changes both for individuals and organisations. As a highly effective means of supporting training and development initiatives to ensure that key skills are transferred back in to the workforce coaching will ensure that the interventions developed become embedded in behaviours and become the way we do things around here. Using individuals within work areas to coach/mentor (like the Jönköping Esther Coaches) has been shown to be an effective way of ensuring that the skills developed by individuals during Improvement interventions are spread across the organisation, while at the same time developing the confidence of Page 11 of 18

individuals in the value of their contribution to the performance of the organisation. 3.6 How ABCi will support performance improvement It is important to understand how an quality improvement will contribute to the performance of the Health Board, and to apply the rigour of measuring improvement to the creation of ABCi itself. Key high level measures of the effectiveness of ABCi will be: The number of staff trained in quality improvement methodology The number of quality improvement projects delivering measurable improvements in patient experience The number of quality improvement projects delivering measurable improvements in clinical outcomes without increasing costs The number of quality improvement projects delivering measurable reductions in cost with no deterioration in clinical outcome The proportion of time at management meetings spent on the scrutiny of measures of improvement Five Welsh Government Tier 1 measures of organisational performance already rely directly on a quality improvement approach, and adopting a more structured QI approach will improve the robustness of their delivery. Of the other Tier 1 measures seven are addressed by either the 100 000 Bed Days (100 KBD) or the Delivering Access through Team Effectiveness (DATE) Priority Change Programmes, both of which will depend on a good quality improvement approach for success (Table 1). Tier 1 Outcome measure Existing QI Approach Priority Change Programme Number of people at home with MH needs or >75 100 KBD Annual Fundamentals of Care audit C. dif & MRSA rates Pressure sore rate 30 day mortality rates 26 and 36 week access targets DATE Unscheduled care 4 h 100 KBD Ambulance handover 100 KBD Cancer 31 and 62 day DATE Stroke bundles Surgery Daycases and LOS DATE Theatres/OPD/demand management DATE Finance Table 1 Page 12 of 18

Examples of quality improvement workstreams that will contribute to achieving the objective of the 100 000 Bed days Priority Change Programme are: Safe Timely Return Home improving patient flow through medical wards Fractured Neck of Femur care bundle approach analogous to the stroke pathway Further reductions in Hospital Acquired Infections Enhanced Recovery After Surgery 1000 Lives Plus collaborative Improved Chronic Conditions management for Chronic Airways Disease, Diabetes and Heart Failure 3.6 How ABCi will improve patient experience One of the fundamental principles of healthcare quality improvement is to ensure that value is improved from the perspective of the patient. Clinical outcomes such as improvement in survival and function are important, but equally important is the experience of care. Care must be delivered with humanity and an appreciation of the patient or service user s point of view. Evaluating and designing care from a patient perspective is an important and growing area of quality improvement work, and will be a focus of activity for ABCi. The Health Board is already taking a quality improvement approach based on patient experience in a number of key areas. A recent programme has been initiated to remodel care for patients with fractured hips and diabetes in association with the Health Foundation and the King s Fund. This uses Patient and Family Centred Care quality improvement methodology, and involves structured shadowing of patients and the direct involvement of patients and carers in developing and prioritising service improvements. 4. Conclusion The Health Board faces the challenge of improving quality with limited resources. Other organisations have embraced a best in class approach to continuous quality improvement, and have demonstrated an impressive ability to improve organisational performance within limited resources. A Centre for Improvement approach will integrate existing improvement approaches across the Health Board with minimal extra investment, and will allow the Page 13 of 18

Health Board to respond effectively to an ambitious Welsh Government agenda to improve quality within a constrained budget. 5. Recommendations That the Board supports the creation of the ABCi Centre for Improvement. That the Board supports the next steps in the creation of the ABCi: The formation of a steering board composed of Executive and Independent Board Members to oversee the creation of the ABCi A communications programme to create understanding of the integrated approach to quality improvement across the health board The appointment of a Director and Programme Manager to create the ABCi Initiation of the HR process to move appropriate staff into the ABCi Dr Grant Robinson Medical Director Anne Phillimore Director of Workforce & OD July 2012 Page 14 of 18

Appendix 1 - Questions and Answers Aneurin Bevan Health Board Q: What areas of the Health Board s work will ABCi address? A: ABCi will provide support for quality improvement in all areas of the Health Board s work, from public health improvement, through support for people living with chronic conditions in the community, to patients admitted for hospital care. Q: How will ABCi help to deliver the Health Board s key performance targets? A: The links between quality improvement and performance delivery are considered in section 3.6 of this paper. Quality improvement supports all areas of performance delivery, either directly or indirectly. Mechanisms for performance management need to run alongside quality improvement work, although it is important that these two activities are held separate, as they require different mindsets. ABCi will work with clinical teams to provide the tools, experience and headspace that will allow performance improvements to be made. Q: How will ABCi help to address the key risks facing the Health Board? ABCi directly addresses corporate risk CRR10 1 it plays a pivotal part in a future focused organisational development strategy to allow active planning for and response to current and future needs by developing staff to deliver a world class service for patients. Quality Improvement work is popular with staff, so ABCI also addresses CRR3, by enhancing the recruitment, retention and development of motivated, engaged and skilled staff to deliver high quality patient care. The ABCi focus on patient experience will address CRR7 to help meet the public and patient experience and dignity of care expectations. ABCi is directly targeted at risk CRR 5 - to meet key Welsh Government Annual Quality Framework and performance indicators. Quality improvement methodology has already been used to make significant progress against risk CRR2, to improve infection control and will make a significant contribution to CRR 1 the need for the Health Board to live within its financial means. ( 1 Please note that the CRR references relate to the corporate risk register) Page 15 of 18

Q: How will ABCi help to improve patient experience? A: The key role of patient experience in quality improvement is explored in section 3.7 of the paper, and it will be a specific priority of the centre to develop expertise in the improvement of patient experience. Q: Who will be trained in quality improvement? ABCI will support all Health Board members of staff to have some knowledge of quality improvement methods. Board members will receive specific training in leadership for quality improvement, and a core of developed expertise will be made available across the Health Board so that all staff areas and clinical teams have easy access to an individual with QI expertise. Q: Measurement seems to be a key part of quality improvement. What gets measured in a quality improvement programme? A key theme of quality improvement work is if you can t (or don t) measure it, you can t improve it, so deciding what and how to measure at an early stage in an improvement programme is a key step. The precise measure will vary from area to area, but it is important to measure what is important and set this measurement up, rather than just using measures that already exist. A typical improvement programme would include run charts showing process measures (e.g. hand washing for infection control) in pilot areas, spread measures (e.g. showing how many wards were involved in the programme) and outcome measures (e.g. the number of patients who acquired an infection). Q: How are patient pathways used in quality improvement work? Patient pathways are a key tool to develop quality improvement work; they allow work to be centred on the patient across disciplines and operational areas. Often care bundles, detailing a limited number of evidence based measures that must be reliably delivered at each stage of the patient pathway, are defined, and the measurement of their delivery constitutes a key process measure. Q: What is the core quality improvement methodology for ABCi? The Model for Improvement, using Plan-Do-Study-Act cycles (and outlined in section 3.3), is the core methodology, and many Health Board staff already have some familiarity with this through engagement in 1000 Lives Plus work. Other allied quality improvement methodology, such as Lean or Six Sigma, may be Page 16 of 18

useful for specific tasks, and ABCi will also develop some expertise in the use of these other tools. Q: What are the links between Research and Development and ABCi? The department of R&D has been closely involved in the plans to develop a centre for quality improvement and the Assistant Medical Director for R&D has a specific role to develop Quality Improvement within the Deanery. ABCi will specifically develop an evidence base for improvement work and will foster innovation across the Health Board to improve quality and patient experience without increasing costs and to reduce cost of care without compromising quality. Q: What are the links between Training and Education and ABCi? ABCi will have close links with training for all professional disciplines to meet the Welsh Government s ambition for staff training in quality improvement. Key health board staff involved in training will closely aligned to the work of ABCi. Q: How can we develop champions for quality improvement across the Health Board? It is important that awareness of quality improvement reaches all areas of the Health Board, and ABCi will work with the Partnership Forum and the Professional Forum to develop champions for quality improvement across the Health Board. Q: How does ABCi fit with other initiatives aimed at making Aneurin Bevan Health Board a learning organisation? ABCi is closely aligned with Putting Things Right in that it seeks to build a process of improvement based on accurate knowledge of what is going on in the Health Board. It is important that we learn from what has gone wrong, but also that we celebrate and build on successes in quality improvement Q: Some attempts to improve quality may not work. How do we help staff to be innovative without wasting time on initiatives that don t work? Quality improvement work aims to build a safe environment to try tests of change which are rapidly evaluated through a PDSA cycles so they can be abandoned quickly if they don t work, and built upon and spread if they are successful. Most quality improvement work Page 17 of 18

involves a few weeks of trying things to see what will work best, or to see how to get a particular approach to work in a particular area. How much will it cost to set up ABCi? Most of the staff cost will be found by reassigning staff already involved in QI work in some capacity to ABCi. A Director for the centre will be appointed and some programme management resource will be required to set the centre up and co-ordinate QI activity. The centre will aim to secure funding from external sources wherever possible, and will explore possibilities to market expertise in Quality Improvement beyond the Health Board. Q: How much time will staff involved in improvement activities need to spend away from the workplace? Most quality improvement work takes place in the work environment, although it is important that some time (for example in a team huddle at the beginning of the day) is spent reviewing the current state of improvement work and planning any changes. Done properly this should result in a more effective use of time ( working smart ). In a thirty day improvement cycle staff would typically spend a half day or a day together to plan improvement work. ABCi staff would work ahead of time to prepare for this team time to ensure it is used as effectively as possible. Page 18 of 18