Changing the World

…..in 3 steps?

The next hour (or so…)

• What’s the problem we were trying to solve?

• How did we tackle it?• What has been achieved so far?• How are we expanding the approach?• Why might this matter to you?

Vision, aim and context.

Culture, capacityAnd challenge. How much and by when?

Implementation, measurement and improvement

The 3-step Improvement Framework for Scotland’s public services

In your pack

The six questions to be asked of EVERY change programme:

1) Does everyone in the system know what we are trying to achieve?

2) Are we prioritising the improvements likely to have the biggest impact on the aim and stopping those that have little impact?

3) Is everyone clear about the means of securing improvement towards our aim?

4) Are we able to measure and report progress on our aim?5) Do we know how and where to deploy resources when

improvement is slower than required?6) Do we have a way of testing and innovating and then spreading

new learning?

Q?

JL

NHS improvement language

BundlesReliability

Collaboratives

Which HC professional would you want to go to?

82

84

86

88

90

92

94

96

PracticeA

PracticeB

PracticeC

PatientSatisfaction

Which HC professional would you want to go to?

80

8284

86

88

9092

94

96

PracticeA

PracticeB

PracticeC

PatientSatisfactionAccommodatedAppointments

Which HC professional would you want to go to?

8082

84

8688

90

9294

96

PracticeA

PracticeB

PracticeC

PatientSatisfactionAccommodatedAppointments% of people backto full functioning

Which HC professional would you want to go to?

70

75

80

85

90

95

PracticeA

PracticeB

PracticeC

PatientSatisfactionAccommodatedAppointments% of people backto full functioningHarm-free care

DF

What challenge are we trying to solve?

Current level of HarmUSA 3.7% of admissions 44-98,000 deaths Australia 16% of admissions

250,000 adverse events 50,000 permanent disability

10,000 deathsDenmark 9% of admissionsN.Z. 10% of admissionsUK 11% of admissions 850,000 adverse events

DoH ECRI 2002 Knox K et al

25.1 harms per 100 admissions

Q1

Global Trigger Tool Reviews3 Exemplar Hospitals (900 notes)

40 Bed rural Hospital (300 notes)

10 Hospital Research Project (240 notes)

7 Hospital System (3000 notes)

Multi-state Tertiary System (2000 notes)

Events/1000 Days

83 90 NA 119 86

Events/100 admissions

45 40 37 41 38

Admissions with adverse events

32% 30% 30% 29% 30%

Mid-Staffs

Families have described “Third World” conditions at the trust, with some patients drinking water from vases because they were so thirsty and others screaming in pain. The Healthcare Commission launched an inquiry after concerns were raised about higher-than-normal death rates in emergency care, in particular at Stafford Hospital. The trust argued that the anomalies were due to problems with its recording of data rather than the quality of care for patients, the report said. Times online March 2009

Q1

Evidence based medicine Evidence based care delivery

17 years to get 14% of evidence into practice

Q1

How did we set out to solve it?

“quality improvement”The combined and unceasing efforts of everyone – health care professionals,

patients and their families, researchers, payers, planners, administrators,

educators – to make changes that will lead to

better patient outcome, better system performance, and better professional

development.

Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

Policy Options

• Do what we’ve always done• Let’s get more data• Run a pilot project• Run a campaign• Let Boards and hospitals decide what to

do• Run a mandatory national improvement

programme

So why did Scotland go national?

• The context was right• Our size helped• Clinicians and managers were receptive• A good match with ‘values’• The evidence was good enough – the

Tayside effect• It felt like the right thing to do

Our response to the 6 Questions

The six questions to be asked of EVERY change programme:

1) Does everyone in the system know what we are trying to achieve?

2) Are we prioritising the improvements likely to have the biggest impact on the aim and stopping those that have little impact?

3) Is everyone clear about the means of securing improvement towards our aim?

4) Are we able to measure and report progress on our aim?5) Do we know how and where to deploy resources when

improvement is slower than required?6) Do we have a way of testing and innovating and then spreading

new learning?

Q1-6

It’s complicated….

Too bad all the people who know how to run the country are busy driving cabs and cutting hair.

-- George Burns

“Conquering the world on horseback is easy: it is dismounting and governing that is hard”

Genghis Khan

JL

IHI Breakthrough Series Collaborative

Select Topic

(develop mission)

Planning Group

Develop Framework & Changes

Participants (10-100 teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports Email (listserv) Phone Conferences

Visits Assessments

Monthly Team Reports

Dissemination

Publications, Congress. etc.A D

P

SExpert

Meeting

AP1 AP2 AP3*

LS – Learning Session

AP – Action Period

*AP3 –continue reporting data as needed to document success

Holding the Gains

Q3

Q6

The Improvement Guide, API

Aim

Measures

Changes

Execution

How has the frontline done it?

• Get goals.• Get bold.• Get together.• Get a model (and stick with it)• Get patients and families

• Get the facts.• Get to the field.• Get a clock.• Get the numbers.• Get the stories.

Q2

Q3

Outcome Aims

• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days

between• Central Line Bloodstream Infection: 0 or 300 days

between• Blood Sugars w/in Range (ITU/HDU): 80% or > w/in

range• MRSA Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction

Q2

Q3

What can be achieved?

HSMR

Hospital Standardised Mortality Ratio

Scotland – 7% reduction in HSMR

0.5

0.8

1.0

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Oct-Dec2006

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Q4

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tality

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2008

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2009

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Jul-Sep2010

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0.5

0.8

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1.5

Oct-Dec2006

Jan-Mar2007

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2007

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2008

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Jan-Mar2009

Apr-Jun

2009

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Apr-Jun

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Jul-Sep2010

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Jan-Mar2007

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2008

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HSMR results 2008-2011

Q4

Q5

Scotland level results

Central line infection rate (per thousand line days)

0

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12

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08

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8

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8

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9

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0

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0

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11

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1

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1

March 2011:zero central line infections

in whole country

Q4

VAP rate (per thousand ventilator days)

02468

101214161820

Jan-

08

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-08

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8

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9.11

3.49

62% reduction

Q4

% ICU mortality

10

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1416

18

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2224

26

28

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8

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1

18.2%

15.7%

14% improvement

Q4

General ward C.Difficile rate(per thousand patient days)

0

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8

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1.18

0.14

88% reduction

Q4 Q5

How has NHSScotland done it?

Policy Leadership Execution

Structure Process Outcome

Donabedian, A.

Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment.1980.

Having the best professionals in the world

is no longer enough

© 2010 Institute for Healthcare Improvement

To build a sustainable infrastructure that produces highly reliable QI excellence

by (fill in the date).

How good? By when?

The Capacity and Capability AimQ4

© 2010 Institute for Healthcare Improvement

Who needs to be developed?

Governance?Executives?Managers?

Supervisors?Front Line Workers?

Improvement Advisors (IAs)?

Adapted from Tom Nolan, Associates in Process Improvement presented at the IHI Strategic Partners Roundtable, April 17-18, 2006

Q4

© 2010 Institute for Healthcare Improvement

√

How many quality experts do we need?

Two suggestions for determining this number:

Number of employees

Or…consider that no employee should be more than 2 steps (individuals)

away from a QI expert.

Q4

DF

Moving beyond safety

Q6

What patients see as high quality healthcare?

• caring and compassionate health services;

• collaborating effectively with clinicians, patients and others;

• confidence and trust in health services;• providing a clean care environment;• improving access and the continuity of

care;• delivering clinical excellence

The Healthcare Quality Strategy for Scotland

• Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.

• Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.

• Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

Q2

The 3-step improvement framework for

Scotland’s public services

“Do not be content with mediocrity. Do your job so well that nobody could do it better.”

Martin Luther king Jr.

Macro system –Vision, aim and context.

Meso system –Culture, capacityAnd challenge. How much and by when?

Micro system –

Implementation, measurement and improvement

The 3-step Improvement Framework for Scotland’s public services

Step 1; Changing the world – an evidence base

•This is the macro-system’s role: vision, strategy and building coalitions. “Aims create systems” – W. Edwards Deming•It must establish a vision, a theory of reform, an engagement strategy and an understanding of context both of people and places – then improvement is likely.

Kotter’s eight steps for change offers a framework for work at this level

Step 1; (in our context) – 7 points to change the world

• A compelling vision• A story• Actions/ Stepping stones• Securing the improvement• Engaging the workforce• Making the change work locally (everywhere)• Resilience and authorisation provided by a

guiding coalition

Step 2; Creating the conditions

• This is the meso-system’s role: Capacity and capability building, • It must communicate the changes, empower the citizens and workforce,

model and change the culture.

The six questions to be asked of EVERY change programme:

1) Does everyone in the system know what we are trying to achieve?

2) Are we prioritising the improvements likely to have the biggest impact on the aim and stopping those that have little impact?

3) Is everyone clear about the means of securing improvement towards our aim?

4) Are we able to measure and report progress on our aim?5) Do we know how and where to deploy resources when

improvement is slower than required?6) Do we have a way of testing and innovating and then spreading

new learning?

Step 2; Creating the conditions

The public services improvement bundle

The six questions to be asked of EVERY change programme:

1) Aim? yes/no2) Correct changes? yes/no3) Clear change theory? yes/no4) Measurement? yes/no5) Capability? yes/no6) Spread plan? yes/no

Only proceed if all six are yes – all-or-none measurement.

Step 3; Executing the change

• There are many change theories and models. We must choose a small number of improvement methods and stick with them for the long haul.

• They must all be based on the simple formula of aims/measures and changes.

• Our selection may be; Collaboratives Benchmarking and

competition User/ Community

empowerment Performance management

• The choice must be explicit and evidenced.

• This is the micro-system’s role: all improvement is local. • Will and ideas are not enough at this level – we need execution. We

need a theory of change and the ability to test and implement the changes.

© 2010 Institute for Healthcare Improvement

Key Components Self-Assessment • Will (to change)• Ideas• Execution

• Low Medium High• Low Medium High• Low Medium High

How prepared is your organization?

1941, William A. Foster

"Quality is never an accident; it is always the result of high

intention, sincere effort, intelligent direction and

skillful execution; it represents the wise choice of

many alternatives.”

3 lessons in 3 minutes

• Pay attention to culture– Changing ‘our’ world – Inclusive – workforce– Various approaches available

• Leadership attention – walkarounds• Improvement vs performance

– Organising for quality– Data– Can we test the approach elsewhere?