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Introduction to Improvement
Day 1
2
Your facilitators today are:-
Amanda HuddlestonImprovement Lead: MSc,QN, HV, RN.
&Wendy Stobbs
Improvement Lead: MA, MSc, RGN.
3
4
Agenda Day 1
9.00 Registration & Coffee
9.30Housekeeping and Introductions Setting the scene for Barts and AQuA work
10.00 QI Theory & Context – Quality & Improvement11.00 Coffee 11.15 QI Theory & Context – Change & Human Factors12.30 Lunch 13.15 Diagnosing your Problem14.00 Aim Statements14.45 Coffee 15.00 Driver Diagrams16.15 Summary , Homework & Evaluation16.30 Close
Setting the Scene for the Safety work
at Barts
Setting the Context
AQuA Quality Improvement TrainingDr. Charlotte Hopkins
Context
• First do no harm• Don Berwick‘….routinely collect, analyse and respond to local measures that serve
as early warning signal of quality and safety problems such as the voice of the patients and the staff, staffing levels, the reliability of critical
processes and other quality metrics. These can be smoke detectors as much as mortality rates are, and they can signal problems earlier than
mortality rates do’
How do we know care is safe?
Quality and Safety: the challenges• CQC ratings of ‘Inadequate’ for Whipps Cross, Newham and The
Royal London plus the Margaret Centre at Whipps Cross
• Trust placed in Special Measures
• CQC found a lack of safety focus across the organisation. For example:
The application of early warning systems to assist staff in the early recognition of a deteriorating patient was varied.
The National Early Warnings System (NEWS) had not yet been implemented consistently.
Safe and compassionate – our improvement plan priorities
• Safe and effective care: making safety an absolute priority at all times• Workforce: making sure we have the right number and mix of staff across
our services at all times• Outpatients and medical records: making our systems more reliable so
they support staff to do their jobs and patients to get the care they need• Emergency pathway and patient flow: making sure patients get care and
treatment in a timely way• Compassionate care and patient experience: making sure patients are
always treated with dignity and respect• End of life care: making sure there are appropriate care plans for those
patients nearing the end of their life• Leadership and organisational development: strengthening the way the
Trust is run and making sure staff have all the support they need
Our Quality and Safety Priorities• To further embed safety into our culture.
• Provide support and opportunity for staff in developing their capability and capacity in quality improvement.
• Quality Improvement Collaborative to share good practice, accelerate improvement across the Trust and build a quality improvement system based on a core methodology.
• Sepsis, Preventing Acute Kidney Injury, Falls, Failure to Rescue, Pressure Ulcers, VTE, 5 stage WHO checklist
Has patient care been safe in the past? Ways to monitor harm include:• Safety Cross data• Number of hospital visits due to harms• Reporting of incidents by staff members
Are our clinical systems and processes reliable? Ways to monitor reliability include:• Use of a falls checklist• percentage compliance with all
elements of the pressure ulcer care bundle.
Is care safe today? Ways to monitor sensitivity to operations include:• safety walk-rounds • meetings, handovers• day-to-day conversations• staffing levels• patient or carers interviews to identify
threats to safety.
Will care be safe in the future? Possible approaches for achieving anticipation and preparedness include:• safety culture analysis and safety
climate analysis• safety training rates• sickness absence rates
Are we responding and improving? Sources of information to learn from include: • How are you using the
information in Quality & Safety meetings?
• Can you demonstrate improvement over time?
A framework for the measurement and monitoring of safety
Source: Vincent C, Burnett S, Carthey J.
The measurement and monitoring of safety. The Health Foundation,
2013
Experts / faculty Few numbers
<1%
Improvement champions who are
operational leaders 3%
(√WX staff ) who have improvement knowledge and skills
which can be applied to improvement projects who are
improvement leads in their clinical areas
All staff need awareness with communication of the skills and strategy
Basic introduction to QI – half day course
To work in partnership with expert organisations to develop our own experts and faculty and talent spot within the organisation
Identify and develop new improvement roles working alongside teams
The partner organisation will train 3 full time staff members to develop our own internal sustainable resource
Staff who show enthusiasm and talent will be given opportunities to progress through these levels to continually build expertise and skills
The different levels of capability within an organisation
Why partner?
Who are AQuA
Who are AQuA?Advancing Quality Alliance
• North West health improvement organisation• Membership: Acute, Primary care, Community, CCG,
Mental health and Ambulance trusts across North West England
• Its mission is to stimulate innovation, spread best practice and support local improvement in health and in the quality and productivity of health services
17
Working Together to ImproveAQuA is unique to the NHS. It has not been established by a central edict but as a result of NHS staff and organisations working together to bring about improvements for patients. As a membership organisation, AQuA’s success relies on strong and active engagement from its members.
18
AQuA’s Key Principles• We can achieve more by working together than in
isolation• Improvements must be owned from front line staff to
Boards and leaders• Use robust evidence based improvement methods• As a membership organisation we will only succeed
with active and engaged members
Values Banner?!
19
Skills Escalator for Safety
Introduction to Improvement for Safety (I2I4S)-
an Overview
Programme AimsAim- for delegates to achieve Level 1 / Novice level of the Academy Skills Escalator.Objectives are for individuals:• To appreciate the foundations of theory of quality improvement for
safety and the how this is relevant in the current NHS context• To provide delegates with tools, techniques and concepts which will
help them:– Plan an improvement initiative– Engage people in an improvement initiative– Deliver an improvement initiative– Evaluate an improvement initiative– Sustain and spread an improvement initiative– To provide an opportunity for delegates to practically apply the
tools to an organisational relevant improvement initiative22
Programme ExpectationsAQuA
• Core facilitators/link names• Copies of presentations via
email• Support to develop
improvement initiative• Evaluations acted upon
You• Attendance at all 3 workshops • Print out all materials required• Development of your
improvement project • Submission and delivery of
completed project case study• Evaluations and reflective log
completed• Consider how Links to PDP &
skills development framework23
Learning Objectives for the Day
To introduce you to the theory and context of quality improvement in the NHS
To provide an understanding of how to plan and refine an improvement initiative
To allow you to practically apply this to your own initiative
24
Available in the Tool Kit
Available on AQuA Portal
Reflection point
25
What is the evidence to support the need?
Who has an interest in this area? Would they be on your expert panel?
How is it aligned to your organisation’s quality and safety strategy?
Who are your stakeholders?
How will it impact patient care, staff satisfaction & involvement and the wider health economy?
Initiative Rationale
26
Getting to Know You
Please take a post-it note from your desk and write a random fact about yourself on it – it can be work or non-work related and the more random the better!
You must be willing to share your fact during the course, and it must be something that can be shared in
public but please keep it secret for now!
Please write your name at the bottom, fold it up and give it to one of the facilitators
28
QI Theory & Context- Quality & Safety
What does quality mean?• To you as a consumer?• To you as an employee?• To your organisation?• To your patients/clients/service users?• Describe it – what does it
look/feel/sound/smell like?
30
QI Isn't A New Thing, It’s the Right Thing
Scuatari Barracks Hospital Turkey 1854
32
Florence Nightingale (1859) Notes on Hospitals
150+ years later…“.. is of paramount importance in
terms of quality of care and to delivering ... long history of efforts to embed more systemically in the NHS, widely recognised across the health system that the pace of change is too slow…..’cultural barriers’ to ensuring that patients are as as they could be.”
The NHS Outcomes Framework 2011/12 p29
patient safety
better health outcomespatient safety
safe
33
Francis. Feb 13
Berwick. Aug 13
Keogh.July 13
5 Yr FV2014
Maintaining Safety in our Current Climate
Safe
Improvement science and profound knowledge
Patient Centered
Quality Healthcare
Timely EfficientEquity Effective
6 Dimensions of Quality Healthcare
36
Sustainability
IOM (2001) Crossing the Quality ChasmSustainability was added: Future Hospital Commission (2013)
Future Hospital: Caring for Medical Patients
Safe
Improvement science and profound knowledge
Patient Centered
Quality Healthcare
Timely EfficientEquity Effective
6 Dimensions of Quality Healthcare
37
Sustainability
IOM (2001) Crossing the Quality ChasmSustainability was added: Future Hospital Commission (2013)
Future Hospital: Caring for Medical Patients
THE DARZI ‘3’5 YEAR FORWARD
The Quality Pioneers
38
W Edwards Deming1900-93
American engineer, statistician, professor, author, lecturer, and management consultant
Scientific pioneer of quality control.
Walter Shewhart1891-1967
American physicist, engineer and statistician
Father of statistical quality control. Invented the Shewhart Cycle
Joseph Juran1904-2008
Romanian born American management consultant and engineer
Advocate of quality & quality management
Two Types of Knowledge
Subject Matter Knowledge
Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge.
Profound Knowledge: The interaction of the theories of systems, variation, knowledge, and psychology.
Profound Knowledge
40
Deming’s System of Profound Knowledge
Appreciation for a System• Interdependence, dynamism• World is not deterministic• Optimization, interactions• Containing systems, subsystems
Understanding Variation• Variation is to be expected• Common or special causes• Ranking, tampering• System capability
Theory of Knowledge• Prediction• Learning from theory,
experience• Operational definitions • PDSA for learning and
improvement
Psychology of change• Interaction between people• Motivation• Beliefs, assumptions inferences
From L. Provost41
Deming’s System of Profound Knowledge
The aim of this chapter is to provide an outside view – a lens – that I call a system of profound Knowledge. It provides a map of theory by which to understand the organizations that we work in.”
(Deming 1993 p. 92)
Appreciation of a System
Understanding Variation
Theory of Knowledge Psycholog
y
Subject Matter Knowledge
Knowledge for
Improvement
42
Quality Improvement for Safety
45
Quality
Old Way versus the New Way
QualityBetter BetterWorse Worse
Old Way(Quality Assurance)
New Way(Quality
Improvement)
Threshold
No action taken here
Action taken on all
occurrences
Action taken here
Improvement Science- What is it?
Improvement science is an emerging field of study focused on the methods, theories and approaches that facilitate or hinder efforts to improve quality and the scientific study of these approaches.
Source: The Health Foundation, Improvement Science Evidence Scan, Jan 2011
‘We propose defining it as, the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better outcomes (health), better system performance (care) and better professional development (learning).’
Paul Batalden & Frank Davidoff 2007
Improvement Science What is it?
Improvement science is an emerging field of study focused on the methods, theories and approaches that facilitate or hinder efforts to improve quality and the scientific study of these approaches.
Source: The Health Foundation, Improvement Science Evidence Scan, Jan 2011
‘We propose defining it as, the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better outcomes (health), better system performance (care) and better professional development (learning).’
Paul Batalden & Frank Davidoff 2007
How do we make things better?
Paul BataldenProfessor The Dartmouth Institute for Health Policy and Clinical Practice
Don BerwickPrevious Administrator of the Centers for Medicare and Medicaid Services & CEO of IHI
Helen BevanNHS Improving Quality
Quality Improvement Leaders
48
Change Concepts
Eliminate Waste1. Eliminate things that are not used2. Eliminate multiple entry3. Reduce or eliminate overkill4. Reduce controls on the system5. Recycle or reuse6. Use substitution7. Reduce classifications8. Remove intermediaries9. Match the amount to the need10. Use Sampling 11. Change targets or set points
Improve Work Flow12. Synchronize13. Schedule into multiple processes14. Minimize handoffs15. Move steps in the process close
together16. Find and remove bottlenecks17. Us automation18. Smooth workflow19. Do tasks in parallel20. Consider people as in the same system21. Use multiple processing units22. Adjust to peak demand
Optimize Inventory23 Match inventory to predicted demand24 Use pull systems25 Reduce choice of features26 Reduce multiple brands of the same
item
Change the Work Environment27. Give people access to information
28. Use Proper Measurements
29. Take Care of basics
30. Reduce de-motivating aspects of pay system
31. Conduct training
32. Implement cross-training
33. Invest more resources in improvement
34. Focus on core process and purpose
35. Share risks
36. Emphasize natural and logical consequences
37. Develop alliances/cooperative relationships
Enhance the Producer/customer relationship
38. Listen to customers
39. Coach customer to use product/service
40. Focus on the outcome to a customer
41. Use a coordinator
42. Reach agreement on expectations
43. Outsource for “Free”
44. Optimize level of inspection
45. Work with suppliers
Manage Time46. Reduce setup or startup time
47. Set up timing to use discounts
48. Optimize maintenance
49. Extend specialist’s time
50. Reduce wait time
Manage Variation
51. Standardization (Create a Formal Process)
52. Stop tampering53. Develop operation definitions54. Improve predictions55. Develop contingency plans56. Sort product into grades57. Desensitize58. Exploit variation
Design Systems to avoid mistakes
59. Use reminders60. Use differentiation61. Use constraints62. Use affordances
Focus on the product or service
63. Mass customize64. Offer product/service anytime65. Offer product/service anyplace66. Emphasize intangibles67. Influence or take advantage of fashion
trends68. Reduce the number of components69. Disguise defects or problems70. Differentiate product using quality
dimensions
Added for 2nd Edition71. Change the order of process steps72. Manage Uncertainty, Not Tasks
Reference: The Improvement Guide, 2nd Ed. Langley, Nolan, Nolan, Norman Provost, Appendix A; pgs. 357-408
A P
DS
Plan
DoStudy
Act
AIM: What are we trying to accomplish?
MEASURES: How will we know if achange is an improvement?
CHANGE: What changes can we makethat will result in improvement?
Model for Improvement
51
Empathy the Human Connection to Patient Care Video
The Wigan Empathy video
52
Coffee Break
53
Do you have an initiative in mind?
What does your initiative mean to people (patients, staff, carers,
family, friends)?
54
What is the evidence to support the need?
Who has an interest in this area? Would they be on your expert panel?
How is it aligned to your organisation’s quality and safety strategy?
Who are your stakeholders?
How will it impact patient care, staff satisfaction & involvement and the wider health economy?
Initiative Rationale
55
Exercise: Building the Components of Profound Knowledge
Consider the system that you will seek to improve.• Discuss the issues related to the project that arise from
each component of the System of Profound Knowledge:– which systems will your project impact?– what variation do you know about or expect?– how will your project impact people (colleagues, team
members, other depts)? – what beliefs do you have about your project and how
will you test them?• And what do you bring to it personally?
56
Deming’s System of Profound Knowledge
Appreciation for a System• Interdependence, dynamism• World is not deterministic• Optimization, interactions• Containing systems, subsystems
Understanding Variation• Variation is to be expected• Common or special causes• Ranking, tampering• System capability
Theory of Knowledge• Prediction• Learning from theory,
experience• Operational definitions • PDSA for learning and
improvement
Psychology of change• Interaction between people• Motivation• Beliefs, assumptions inferences
From L. Provost57
Change
What does change mean to you?
59
Change• To cause to be different• To give a completely different form or appearance to;
transform• To give and receive reciprocally• To exchange for or replace with another• To lay aside, abandon, or leave for another; switch: change
methods; change sides.• To put a fresh covering on• To become different or undergo alteration• To undergo transformation or transition• To go from one phase to another
http://www.thefreedictionary.com/change
http://www.thefreedictionary.com/change
60
Why do we need to change things anyway?
61
Paul BataldenDartmouth Medical School, New Hampshire, USA.
“Every system is perfectly designed to get the results it achieves”
62
Systems and Processes
63
Input Action Output Input Action Output Input Action Output Input Action Output
Systems and ProcessesProcess• Series of steps that are
connected and achieve an outcome
• Definitive start and end point (scope)
• Defined user group/product• Usually links to other
processes
System• A collection of processes
organised around a purpose• Impact on those above,
below or embedded• Coordinated activity
between each system• Think ripples on a pond
64
65
Reactive change• Made to solve immediate
problems or react to a special circumstance.
• Often result in putting the system back to where it was sometime before.
• Result is usually felt immediately or in the near future
Proactive change• Initiate changes before
problems occur• Causing something to
happen rather than waiting for it to happen
• Result felt later on-not always obvious
67
Reactive vs Proactive
Human Factors
DefinitionHuman factors encompass all those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work.
Implementing human factors in healthcarePatient Safety First “How to guide” 2010 version
70
Everywhere………
71
Why are Human Factors so Important?
Human error is estimated to account for:• 70% of aviation disasters• 70% of shipping incidents• 85% of shuttle incidents at NASA
In healthcare?• 80% of healthcare errors
72
Buses analogy
73
What’s your data telling you?
66 seats
Even more alarming……..
74
HEALTH CARE
Why are errors happeningTraditional approach to human error:
– The sources of error are bad people– Seek out and apportion blame– Remove individual from system = improve patient
safety– Fails to learn lessons
77
Traditional responses for reducing Error1. Telling people to “make fewer mistakes” is not
effective at reducing error2. Writing new detailed policies is not necessarily
effective at reducing error3. Punishing individuals for making mistakes is not
effective at reducing error4. Remove individual from system = improve patient
safety
78
Reducing ErrorStudies have shown that the best way of reducing error
rates is to target the underlying systems failures, rather than take action against individual members of staff
• the perfection myth: if people try hard enough, they will not make any errors;
• the punishment myth: if we punish people when they make errors, they will make fewer of them.
79
Or maybe…
1. Redesigning systems to protect against error 2. Educating staff about the causes of error, error
detection and error correction 3. Educating patients about personal hospital safety
…are more effective approaches to reducing error???Admission video link
80
Failure• In any complex system faults, errors and failures are
inevitable• This applies to equipment / technology and to human
beings• Most of these are of relatively little consequence and do
not result in adverse consequences• Serious adverse incidents are usually the result of a
sequence of lesser failures and errors• Critical systems need to be designed to cope with errors
or failures
81
When everything slots into place…….
© AQuA Academy 82
Distraction
Understaffed
Poor Guidelines
Adverse / Never Event
James Reason’s Swiss Cheese Model
Causes of Failure• Latent conditions
– Organizational failures & systems design– Present in all systems for long periods of time– Increase likelihood of active failures
• Active Failures– Errors at the time of the event– Unsafe acts (errors and violations) committed at the “sharp
end” of the system– Have direct and immediate impact on safety, with potentially
harmful effects
83
Latent Conditions• Exist within organisation, systems and processes• Poor design of equipment or systems• Poor guidelines or lack of guidelines• Adverse environmental factors• Poor working conditions• Lack of resources (e.g. understaffing)• Poor training and education
84
“Active Failures”
Unsafeacts
Unsafeacts
Unintendedactions
Intendedactions
Basic Error Types
Mistakes
Violations
Skill based errorsAttentional failures
Skill based errorsMemory failures
Rule BasedKnowledge Based
Routine ReasonedReckless
Malicious
Slips
Lapses
85
Top tips – Combatting ErrorReduce potential for error:• Good education and training• Reduce distractions and workload• Appropriate staffing and resources• Appropriate and understandable procedures• Accessible, easy to use SOPs• Proper equipment• Appropriately designed technology
87
Remember – Safety vs Efficiency• Efforts to Improve efficiency often look to remove
steps considered to be “wasteful”• This can also improve safety as processes with
more steps have a higher risk of failing• However, safe systems also have redundant steps
(steps which may detect and error or failure)• Caution not to remove important redundant steps
88
Diagnosing your Problem
90
Sometimes its obvious when things need to change…
91
Three Modes of Thinking• Creative thinking, which results in new ideas• Logical positive thinking, which is concerned with
how to make a new idea work• Logical critical thinking, which is focused on finding
problems in the new idea
It is usually better for a group to engage in one type of thinking at a
time92
Improve or Innovate?Improvement – small
incremental changes. Doing the same thing but doing it
better
Innovation – an idea that breaks with the usual way of thinking
93
Solution V’s Problem
© 2014 AQuA
But before we start…………do you really understand the problem??
Solution vs Problem
How do you know what needs improving?
We benchmark poorly
We’re failing our target
Patients who complain
Our Outcomes are poor
Quantitative data
Patients we interview
Qualitative data
Staff feedback
5 Whys• This could take any number of “whys” to get to the
root cause of the problem• Do not stop until you reach what you believe is a
“cause” and not a “symptom”• If you reach a cause that cannot be controlled, such
as weather, go back one level and see if eliminating that cause will help
© AQuA Academy 97
Why, why, why?!‘Results indicate that when preschoolers ask "why" questions, they're not merely trying to prolong conversation, they're trying to get to the bottom of things.’
© 2014 AQuA
http://www.sciencedaily.com/releases/2009/11/091113083254.htmFrazier et al. Preschoolers' Search for Explanatory Information Within Adult-Child Conversation. Child Development, 2009; 80 (6): 1592 DOI
Process Maps
© 2014 AQuA
Process Map
Value Stream Map
Diagrams
© 2014 AQuA
Spaghetti
Fishbone
Fishbone DiagramA systematic and structured method for identifying
potential root causes of failures
– Classifies potential causes for a failure into five separate categories
– Very logical and analytical method of determining potential causes for failures
© AQuA Academy 103
Group Work
104
Analysing qualitative data
Thematic analysis: Look for the
common themes
Construct a story around typical
findings
The power of a good quote
106
The Patient Perspective
108
Resources/references• http://www.bbc.co.uk/news/uk-england-london-18814487• http://www.pickereurope.org/improvingpatientexperience• http://www.institute.nhs.uk/productives/15stepschallenge/15stepschallenge.
html• http://www.institute.nhs.uk/• http://www.patientexperiencenetwork.org/• http://www.nhsconfed.org/priorities/Quality/Pages/Delivering-great-patient-e
xperience.aspx• http://www.ihi.org/knowledge/Pages/IHIWhitePapers/AchievingExceptionalPa
tientFamilyExperienceInpatientHospitalCareWhitePaper.aspx• http://www.patientvoices.org.uk/• http://www.mindtools.com/CommSkll/ActiveListening.htm
110
References/resourcesPatient opinion 2010; What Patients think about our NHS The Intelligent Board, 2010; Patient Experience; Dr Foster IntelligenceNHS west Midlands Aug 2009; A guide to capturing and using patient, public and service user feedback effectivelyBrown H, Davidson D, Ellins J (2009) Real-time Patient Feedback. Birmingham: Health ServicesManagement Centre, University of Birmingham (for NHS West Midlands)Institute for innovation and improvement; The rough guide to experience and engagement for GP ConsortiaNHS Institute for Innovation and Improvement, Experience Based Design, approach guide and toolkit, www.institute.nhs.uk/quality_and_value/introduction/experience_based_design.htmlDepartment of Health, 2008, High Quality Care for All, LondonDepartment of Health, 2008, The Operating Framework for the NHS in England 2009/10, LondonDepartment of Health, 2009, The NHS Constitution, LondonDepartment of Health, 2007, World Class Commissioning: Competencies, London Cabinet Office, 2009, Working together: public services on your side, London Department of Health, 2008, ‘Measuring the experience of patients/users’, www.dh.gov.uk/en/Publicationsandstatistics/PublishedSurvey/NationalsurveyofNHSpatients/DH_087516Department of Health 2009b Improving Patient Experience. Transforming services using patient experience feedback.www.dh.gov.uk/ppeDepartment of Health 2009 Understanding what matters: A guide to using patient feedback to transform servicesHealthcare Commission, 2007, Is anyone listening? A report on complaints handling in the NHS
111
Planning your Improvement Initiative
Setting Aims
Why do we need an Aim?
• Improvement requires setting aims.
• An organisation will not improve without a clear and firm intention to do so.
Adapted from
114
A P
DS
Plan
DoStudy
Act
AIM: What are we trying to accomplish?
MEASURES: How will we know if achange is an improvement?
CHANGE: What changes can we makethat will result in improvement?
Model for Improvement
115
Do you have an initiative? Why did you choose that topic
There:• Is a gap between science and practice• Are examples of better performance • Is a good “business case” to change• Is there a safety concern?
116
What is the evidence to support the need?
Who has an interest in this area? Would they be on your expert panel?
How is it aligned to your organisation’s quality and safety strategy?
Who are your stakeholders?
How will it impact patient care, staff satisfaction & involvement and the wider health economy?
Initiative Idea Rationale
117
Link to Quality
SafeTimelyEffectiveEfficientEquitablePatient
Centred
Crossing the Quality Chasm: A New Health System for the 21st Century, 2001 Institute of Medicine
118
Setting an Aim• What are you trying to accomplish?• By how much? • By when? • For whom(or what system)?
119
Aim StatementGood Bad
We aim to reduce harm and improve patient safety for all of our internal and external customers.
By June of 2012 we will reduce the incidence of pressure ulcers in the critical care unit by 50%.
Our outpatient testing and therapy patient satisfaction scores are in the bottom 10% of the national comparative database we use. As directed by senior management, we need to get the score above the 50th percentile by the end of the 1st Quarter of 2012.
We will reduce all types of hospital acquired infections.
According to the consultant we hired to evaluate our home health services, we need to improve the effectiveness and reliability of home visit assessments and reduce rehospitalisation rates. The board agrees, so we will work on these issues this year.
Our most recent data reveal that on the average we only reconcile the medications of 35% of our discharged inpatients. We intend to increase this average to 50% by 1/4/12 and to 75% by 31/8/12. 120
Aim Statement• Team name: Lunch time – on time• Aim statement (What’s the problem? Why is it important? What are we going to do about it?) 90% of patients in Bay 1 receive their lunch of choice everyday by 12.30 by November 2014• Whom will it affect? Patients in Bay 1• By how much? 90% will receive choice by 12.30• By when? November 2014
Adapted from
121
Aim Statement• Team name:___________________________ • Aim statement(What’s the problem? Why is it important? What are we going to do about it?)
• Whom will it affect?_____________________• By how much?____________________________• By when?______________________________
Adapted from
122
Coffee Break
123
Driver Diagrams
Driver Diagrams – why use them?• Breaks down any broad aim, graphically, into increasing
levels of detailed actions that must or could be done to achieve the stated aim
• Helps to focus on the cause and effect relationships that exist in complex situations.
• Well defined drivers that can form the focus of improvement efforts.
NHS Tayside 125
What are the component parts?• Aim or goal of the improvement effort
• Primary drivers - system components that contribute directly to the chosen aim or goal. Processes, rules of conduct, structure
• Secondary drivers - elements of the primary drivers and which can be used to create change projects. Components and activities
• Relationship arrows - show the connection between the primary and secondary drivers. A single secondary driver may impact upon a number of primary drivers
NHS Tayside 126
127
90% of patients in Bay 1 receive their
lunch of choice
everyday by 12.30 by
November 2014
Technology- Know what
patients want / need for lunch
Materials-Lunch & equipment
arrives on time
Process- Ward Staff are
available to give out lunch
People- Patients are
available to receive lunch
Menu cards distributedChoices recorded &
communicated
Diet requirements understood
Numbers established & communicated
Time for delivery agreed
Access to ward available
Allocate lunch dutyComplete other tasks prior to
lunch arrival
Staff appropriately trained
Schedule inpatient appts appropriately
Appropriately positioned
Maintained at appropriate temperature
Aim / Outcome Primary Drivers Secondary Drivers
131
Developing Primary Drivers• Dedicate time for team and subject matter experts – ask
them to come prepared!• Revisit your aim statement.• Brainstorm potential Primary Drivers & check
– ’If I made an improvement in this driver what would it achieve?’
– ’If I could influence (or improve) against all of these drivers is there anything else that could go wrong and prevent me achieving my aim?’
NHS Tayside133
134
Developing Secondary Drivers• Look at your Primary Drivers and ask
– What are the main system factors that will impact upon this primary driver?’
– What changes will be made to impact on this?• Brainstorm potential Secondary Drivers & check
– ’If I made an improvement in this driver what would it achieve?’
– ’If I could influence (or improve) against all of these drivers is there anything else that could go wrong and prevent me achieving my aim?’
• Add relationship arrowsNHS Tayside
135
90% of patients in Bay 1 receive their
lunch of choice
everyday by 12.30 by July
2013
Know what patients want / need for lunch
Lunch & equipment arrives on time
Ward Staff are available to give
out lunch
Patients are available to receive
lunch
Menu cards distributedChoices recorded &
communicated
Diet requirements understood
Numbers established & communicated
Time for delivery agreed
Access to ward available
Allocate lunch dutyComplete other tasks prior to
lunch arrival
Staff appropriately trained
Schedule inpatient appts appropriately
Appropriately positioned
Maintained at appropriate temperature
Aim / Outcome Primary Drivers Secondary Drivers
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Group Work
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Home Work• Work through the toolkit and ensure your initiative has an:
• Aim• Driver Diagram
• Give thought to how the patients and staff will be affected and involved
• If you have any measures from your project bring them along
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Learning Objectives for the DayBy the end of this session you will:• Theory & Context
– Have a comprehension of the foundations for quality improvement
– Have a basic awareness of the impact of human factors in healthcare
• Planning your Improvement Initiative– Be able to develop the building blocks for delivering an
improvement initiative through the application of Improvement Tools – including Aim Statements, Driver Diagrams, Problem Solving and Diagnostic Techniques
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Contact AQuA Via:• The website at:
www.advancingqualityalliance.nhs.uk
• The Member Web Portal at: www.aquanw.nhs.uk/users/sign_in
• Email your project lead at Barts: [email protected]
• @AQuA_inform• AQuA-Advancing-Quality-Alliance
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