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David Fillingham: Advancing Quality
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David Fillingham: Advancing Quality

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  • 1. Advancing Quality David Fillingham 7th/8th March 2013 1
  • 2. 2
  • 3. “Up and down the country there are brilliantexamples of pioneering work, great ideas and fantastic improvements in service. But, so often, these are isolated examples” Sir David Nicolson, 2011 3
  • 4. 4
  • 5. How can we get much better at spreading more widelyand more rapidly and what works?• Evidence based care bundles• Technological innovations• Innovations in service design 5
  • 6. • A bit about AQuA• The problem with Sauerkraut• Lessons from experience (it’s the people, stupid)• AQuA’s Model for Spread: - Advancing Quality - Discovery Community on Integration• Some final thoughts and questions 6
  • 7. About AQuA• A membership organisation – funded by 68 CCGs and providers in the North West of England• Our mission is to support our members to improve the quality of healthcare• All sectors, commissioners and providers – a whole system approach• Firmly rooted in the North West but beginning to work more widely• Encouraging radical service transformation• Fully aligned with the North West’s two proposed Academic Health Science Networks 7
  • 8. Industrial Age Information Medicine Age Healthcare• Infectious diseases • Chronic diseases•Hospitals • Community based Services predominate • Prevention and self care• Acute intervention • Integrated delivery network• Silo working • Smart use of technology• Paper based • Shared Decision Making• Doctor knows best 8
  • 9. 9
  • 10. And new for 2013/14…• First Do No Harm… AQuA’s Response to the Francis Report• “Advancing Innovation” – in conjunction with the AHSNs• AQuA Academy support for senior leaders and improvement experts• A strong focus on the needs of frail older people 10
  • 11. The Sauerkraut Problem 11
  • 12. How quickly does innovation spread? – the case of Scurvy amongst Seafarers1497 Vasco de Gamas voyage around the Cape of Good Hope – 100 of 160 men lost to scurvy1601 Captain James Lancaster – controlled ‘trial’ with lemon juice1747 Dr James Lind – confirms citrus as effective1768-80 Captain James Cook – Sauerkraut as a cure1865 British Board of Trade mandates a healthy diet on all marine vesselsTime elapsed from definitive trial to full implementation = 264 years 12
  • 13. Some theoretical perspectives…• Rogers E. – The Diffusion of Innovation, 1995• IHI White Paper – A framework for Spread , 2006• USAID Technical Report – Options for large scale spread of simple high impact interventions, 2010• Greater Manchesters CLAHRC – Spreading Improvement and Innovation, 2010• Greenhalgh et al – Diffusion of Innovations in Service Organisations Mill Bank Quarterly Vol. 82 No. 4, 2004• Dixon-Woods et al – Quality Improvement Through Clinical Communities, Journal of Health Organisation and Management, Vol 26, Issue 2, 2012• Fraser S. – Accelerates the Spread of Good Practice, 2002• Gladwell M. – The Tipping Point, 2000 13
  • 14. 3 interacting factors…• The innovation itself (“stickiness”)• The characteristics of the innovators• The organisational context 14
  • 15. Source: Rogers, E.M. 15
  • 16. “Sauerkraut, Sobriety and the Spread of Change”1. Find sound innovations2. Find and support innovators3. Invest in early adopters4. Make early adopters activity visible5. Trust and enable re-invention6. Create slack for change7. Lead by example Berwick: Escape Fire 16
  • 17. Lessons From Experience (It’s the people, stupid) 17
  • 18. Fillingham’s Motivational Matrix Positive Enthusiastic NaïveOutlook on Life Pragmatist Idealist Disillusioned Embittered Negative Sceptic Cynic High Low Grip on Reality 18
  • 19. Converting the Sceptics• Tackle stress and burnout – develop resilience• Make it specific to ‘my’ service• Use rigorous improvement methods• Robust and convincing data• Hands on experience• Reinforce through changed management system and leadership style 19
  • 20. AQuA’s Model of Spread Evidence and Intelligence Change ChampionsRobust Improvement Incentives and Communities of Methods Practice Peer to Peer Learning 20
  • 21. Advancing Quality - AQ• Programme established in 2007• Adapted from Premier’s HQID programme in the US• Now the dominant Regional CQUINS in the North West• Has significantly improved reliability of evidence based processes leading to improved outcomes and productivity
  • 22. Evidence Based MeasuresAcute myocardial infarction (AMI) Community-acquired pneumonia (CAP) 1. Aspirin at arrival 1. Oxygenation assessment within 24 hours 2. Aspirin prescribed at discharge prior to or after hospital arrival 3. ACE or ARB for LVSD 2. Initial antibiotic selection 4. Smoking cessation advice/counseling 3. Blood culture collected prior to first antibiotic administration 5. Beta blocker at arrival 4. Antibiotic timing, first dose of antibiotics 6. Beta blocker prescribed at discharge within six hours after hospital arrival 7. Thrombolytic received within 30 minutes of 5. Smoking cessation advice/counseling hospital arrival 8. PCI received within 90 minutes of hospital arrival Coronary artery bypass graft (CABG) 1. Aspirin prescribed at discharge 2. Prophylactic antibiotic received within oneHip and knee replacement hour prior to surgical incision 1. Prophylactic antibiotic received within one 3. Prophylactic antibiotic selection for surgical hour prior to surgical incision patients 2. Prophylactic antibiotic selection for surgical 4. Prophylactic antibiotics discontinued within patients 48 hours after surgery end time 3. Prophylactic antibiotics discontinued within 24 hours after surgery end time 4. Recommended Venous Thromboembolism Heart failure (HF) prophylaxis ordered 1. Left Ventricular Systolic (LVS) assessment 5. Appropriate Venous Thromboembolism 2. Detailed discharge instructions prophylaxis within 24 hours prior to surgery 3. ACEI or ARB for LVSD to 24 hours after surgery 4. Smoking cessation advice/counseling
  • 23. Robust data collection Patient 1 Patient 2 Patient 3 Overall Trust ScoresMeasure 1 robust• Need  data   2 of 3 = 66.6%Measure identify  – to 2 opportunities to improve 3 = 100%   3 ofMeasure benchmark – to 3    1 of 3 = 33.3%Measure 4    3 of 3 = 100%• Rules based / algorithmic approachMeasure 5    3 of 3 = 100% – Identifyingof 5 5 of 5 3 of 5Opportunities 4 patient cohorts – every patient 12 of 15 – Data dictionary & reasons for exclusion from atakenComposite measure 80%Process Score 100% 60% 80%Patient 0 of 1 1 of 1 0 of 1 1 of 3• Web based measure data collectionAppropriate Care(all or nothing) – Utilise existing data where availableAppropriate Care    33.3% 23Score
  • 24. A culture of change & collaboration• Regular collaborative learning events• Involvement from all provider & commissioner organisations• Created networks of clinical and non clinical communities• A willingness to share and learn 24
  • 25. Incentives• Additional financial rewards – first 18 months – top performers / top improvers• Absorbed into CQUIN – regional scheme (0.01%)• Benchmarking and friendly competition• Public reporting www.advancingqualitynw.nhs.uk 25
  • 26. Marathon Raised the bar not a sprint! with a new measure!Rapid Steadyimprovement, New improvement, conditionsustained sustained
  • 27. Reducingvariation 27
  • 28. Outcomes & cost effectiveness• Overall (3 conditions) statistically significant reductions in mortality & LoS• NW mortality gain greater than rest of England – >1% point reduction in mortality rate (>5% relative rate) = c890 deaths averted.• >20,000 hospital days saved (~£5m)• >6000 QALYs gained as result of mortality reductions – based on healthy life expectancy of people in general population of same age as the patient population. – Health gain of c£120m (£20k threshold, c£180m @ £30k) – 10 times more cost effective than break-even point
  • 29. AQuA Discovery Community on Integration• We don’t have one accepted “right” model we can copy• We don’t even have a single definition of integration• The aim is to: -Steal with pride from elsewhere (creatively adapting) - Stimulate invention - Accelerate progress by mutual sharing and learning• 8 Health Economies in cohort 1; 11 more in cohort 2 30
  • 30. Discovery Community Model Learning from each other Emerging nationalFaculty input Your policy context Learning National and international case studies 31
  • 31. The Framework Service Design Workforce Leadership • Role design • Skills • Capacity Integration to Improve • SafetyPatient and Carer • Effectiveness Healthcare Infrastructure • Population health value and ITEngagement • Use of resources Financial and Contractual Governance mechanisms Culture 32
  • 32. Richard Gleave 34
  • 33. AQuA’s Model of Spread Evidence and Intelligence Change ChampionsRobust Improvement Incentives and Communities of Methods Practice Peer to Peer Learning AWR “Accelerated Wheel Reinvention” 35
  • 34. A new ‘Context’ for Improvement and Spread 36
  • 35. Some Final Thoughts and Questions…• What are the most important priorities for spread?• Do we have enough “enthusiastic pragmatists”?• Is it “hit and hope” or do we have an aligned, systematic approach?• How can we use the new improvement “context” to our advantage?• How we can counter pessimism and setbacks with resilience, energy and hope? 37

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