How are we doing?

– Implementing Best

Practice

Tuula Rintala, RN, MSc PSPM

Quality Manager, KCH

Jacie Inspector, Collection Facility

KHP Transplant Programme – Brief summary

• KCH

– KCH BMT programme • First autograft 1986

• First allograft 1993

– 1000th transplant June 2008

– 1000th allogeneic stem cell infusion July 2012

• GSTT:

– 1975: BM transplant for a thalassaemia patient

– 1983: NHL transplant (Dept of Oncology)

– 500 transplants by 2005 - over 700 transplants by the

time programmes merged

KHP BMT Programme

• KHP (Kings Health Partners) BMT Programme – Merger completed October 2011

• Largest allogeneic transplant program in the

BMT consortium

– Largest MDS allograft program in the UK/Europe

– Largest Aplastic Anaemia Programme in the UK

• Anthony Nolan Trust collection centre

• JACIE, HTA, MHRA and CPA accredited

1. Unknowing variation in clinical practice and service delivery

2. Errors of commission and omission

3. Waste

4. Failure to implement new knowledge and technology

systematically and appropriately

5. Over-use and under-use – inappropriate care

6. Unsatisfactory patient experience

7. Poor quality clinical practice

8. Failure to manage uncertainty

8 most common problems in health care

What is Quality?

Moullin (2002)

– Quality leads to a service better meeting the patient’s

requirements, and increases patients confidence in

the service; staff is more empowered and higher job

satisfaction; better quality can reduce costs

MacKenzie (2005)

– Multidimensional & changeable concept

– ‘an acceptable compromise’

Donabedian (2005)

– reflection of values and goals current in healthcare and in the larger society

What is Quality?

• US Institute of Medicine: Six dimensions of

healthcare quality

– Safe

– Effective

– Patient-centred

– Timely

– Efficient

– Equitable

4 Pillars of Quality

Say

what

you

do

Do

What

you

Say

Prove

It

Improve

It

QUALITY

Ferlie & Shortell: Model for quality improvement

• Levels of Change

– Individual

– Group /Team

– Organisation

– Larger system /

environment

• Core properties

– Leadership

– Organisational culture

– Team /microsystems

development

– Information

Technology

Implementation

20% ‘tipping point’

‘Kiss of yes’

Problem people

Self-supporting system Not self-supporting system

Pioneers

• Tacit knowledge –

• Held by an individual or shared by a community

• Explicit knowledge-

• Generalisable knowledge

Knowledge from research – evidence

Knowledge from the analysis of audit data – healthcare

statistics

Knowledge from the experience of clinicians and patients

Types of Knowledge

• Class 1 Randomised Controlled

Trials

• Class 2 Prospective, observational,

cohort, prevalence studies

• Class 3 Retrospective clinical,

database/registry, case

report study, expert opinion

• Challenges: Does not include qualitative methods

Traditional View of Evidence

Find the best evidence you can

Find appropriate evidence for your question

Traditional View of Evidence

Barriers to implementing EBP

• Work setting

• Authority to implement; lack of support from doctors & AHPs

• No data on what is already happening / what is being done / what

works

• Sharing the data with the wider team

• Research itself

• Relevance of research, presence of conflicting findings

• Presentation of research

• Readability of research, understanding statistics

• Person

• Ability to find and understand research

• Lack of time; engagement

Do we know

How We Are Doing?

• Collect Data

– Scorecards

– Surveys

– Audits

• Make collecting data easy

– Use & review data hospital collects & evaluates

– Share data

– Make sure everyone knows what the purpose of

collecting data is

• Engage all staff

– Make sure everyone knows what the purpose of

collecting data is

How do you know how you are doing?

Example: BMT Scorecard

How are we doing? –Ask your patients

How are we doing - Ask your customers

0

1

2

3

4

satisfaction

with turnaround

time

satisfaction

with turnaround

time for donor

searches

satisfaction

with

communication

about typing

not at all

not very

quite a bit

very much

don't know

Tissue Typing

0

2

4

6

8

satisfaction

with timing and

frequency of

clinic

appointments

not at all

not very

quite a bit

very much

don't know 0

2

4

6

8

ph

leb

oto

my

wa

itin

g t

ime

s

co

nti

nu

ity

co

mm

un

ica

tio

n

ph

arm

ac

y

pro

ce

du

res

an

d d

ay

un

it

ex

pe

rie

nc

e

not at all

not very

quite a bit

very much

don't know

0

2

4

6

8

10

satisfaction

with availability

of appropriate

staff for advice

our ability to

respond to

queries

accessibility of

beds to

transfer sick

patients

timeliness of

discharge post

bmt/

readmission

bmt co-

ordinators

not at all

not very

quite a bit

very much

don't know

Ask your customers (referring Hospitals)

Learn from Mistakes

What is reported?

Sources of Non-Compliances

(QPulse only; Datix AIs excluded)

Who reports your incidents ?

How can we do better ?

1. Measure what you are doing

– Learning through the process

– Measure over time

2. Understand the process

– Explains WHY the problem exists

– Tool for engaging staff

3. Improve reliability

– Helps to reduce waste in the process (time,

resource & reduces harm

– Consistent care

How can we do better ?

4. Demand, capacity and flow

– Understand the variation in the capacity

available

5. Engage all staff

– How the change is introduced, predicts the

success

– Engaging frontline staff is crucial

6. Involve patients

– Ask - ‘How do we know what constitutes

good care?’

– Patients may define quality differently from

clinicians & managers

Thank you

Tuula.Rintala@nhs.net