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...
The 3-step Improvement Framework for      Scotland’s public services                              Vision, aim and context....
Q?                     In your pack The six questions to be asked of EVERY change programme: 1) Does everyone in the syste...
JL
NHS improvement language Reliability                    Bundles               Collaboratives
Which HC professional would you        want to go to?   96   94   92   90   88                                Patient     ...
Which HC professional would you        want to go to?  96  94  92  90                                    Patient  88      ...
Which HC professional would you        want to go to?  96  94  92                                    Patient  90          ...
Which HC professional would you        want to go to?  95  90                                Patient                      ...
DF
What challenge are we trying to solve?
Current level of HarmUSA       3.7% of admissions          44-98,000 deathsAustralia 16% of admissions          250,000 ad...
Q1     25.1 harms per 100 admissions
Global Trigger Tool Reviews              3 Exemplar    40 Bed rural    10 Hospital    7 Hospital     Multi-state          ...
Mid-Staffs             Families have described “Third World”             conditions at the trust, with some patients      ...
Q1
Q1     Evidence based medicine      Evidence based care delivery       17 years to get 14% of evidence                 in...
How did we set out to solve it?
“quality improvement”The combined and unceasing efforts of         everyone – health care    professionals, patients and t...
Policy Options• Do what we‟ve always done• Let‟s get more data• Run a pilot project• Run a campaign• Let Boards and hospit...
So why did Scotland go           national?• The context was right• Our size helped• Clinicians and managers were receptive...
Q1-6       Our response to the 6 Questions   The six questions to be asked of EVERY change programme:   1) Does everyone i...
It‟s complicated….Too bad all the people who know how to run the country are busy driving cabs and cutting hair.          ...
“Conquering the world on horseback is easy: it   is dismounting and governing that is hard”                Genghis Khan
JL
Q3        IHI Breakthrough Series CollaborativeQ6Select            Participants (10-100 teams)Topic(developmission)       ...
Aim                             Measures                             Changes                             ExecutionThe Impr...
Q2Q3   How has the frontline done it? • Get goals.         •   Get the facts. • Get bold.          •   Get to the field. •...
Q2             Outcome AimsQ3 • Mortality: 15% reduction • Adverse Events: 30% reduction • Ventilator Associated Pneumonia...
What can be achieved?
HSMRHospital Standardised Mortality Ratio
Q4                                     Scotland – 7% reduction in HSMR                               1.5                  ...
Q4                                1.5                                                                                     ...
Scotland level results
Q4          Central line infection rate                 (per thousand line days)     12     10                            ...
Q4           0           2           4           6           8          10          12          14          16          18...
Q4          10          12          14          16          18          20          22          24          26          28...
0.5                               1.5                                                     2.5          0                  ...
How has NHSScotland done it?    Policy                              Leadership   Execution Structure                      ...
Having the bestprofessionals in the world   is no longer enough
Q4     The Capacity and Capability Aim           To build a sustainable       infrastructure that produces       highly re...
Q4     Who needs to be developed?              Governance?               Executives?               Managers?              ...
Q4      How many quality experts             do we need?     Two suggestions for determining this number:              √  ...
DF
Q6     Moving beyond safety
What patients see as high quality           healthcare?• caring and compassionate health  services;• collaborating effecti...
Q2     The Healthcare Quality Strategy for Scotland • Person-Centred - Mutually beneficial partnerships between     patien...
The 3-step improvement      framework forScotland’s public services                   “Do not be content with mediocrity. ...
The 3-step Improvement Framework for      Scotland’s public services                              Macro system –       1) ...
Step 1; Changing the world – an evidence base•This is the macro-system‟s role: vision, strategy and building coalitions. “...
Step 1; (in our context) – 7 points to change the world•    A compelling vision•    A story•    Actions/ Stepping stones• ...
Step 2; Creating the conditions•This is the meso-system‟s role: Capacity and capability building,•It must communicate the ...
Step 2; Creating the conditions          The public services improvement bundleThe six questions to be asked of EVERY chan...
Step 3; Executing the change•This is the micro-system‟s role: all improvement is local.•Will and ideas are not enough at t...
How prepared is your organization?Key Components            Self-Assessment • Will (to change)   • Low   Medium High • Ide...
"Quality is never an accident; it is always the result of high         intention, sincereeffort, intelligent direction and...
3 lessons in 3 minutes• Pay attention to culture  – Changing „our‟ world  – Inclusive – workforce  – Various approaches av...
0945 lomond jason leitch & derek feeley wi updated notes
0945 lomond jason leitch & derek feeley wi updated notes
0945 lomond jason leitch & derek feeley wi updated notes
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0945 lomond jason leitch & derek feeley wi updated notes

  1. 1. Changing the World …..in 3 steps?
  2. 2. 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?
  3. 3. The 3-step Improvement Framework for Scotland’s public services Vision, aim and context. 1) Change the world Culture, capacity And challenge. How much and by 2) Create the conditions when?3) Make the improvement Implementation, measur ement and improvement
  4. 4. Q? 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?
  5. 5. JL
  6. 6. NHS improvement language Reliability Bundles Collaboratives
  7. 7. Which HC professional would you want to go to? 96 94 92 90 88 Patient Satisfaction 86 84 82 Practice Practice Practice A B C
  8. 8. Which HC professional would you want to go to? 96 94 92 90 Patient 88 Satisfaction 86 Accommodated 84 Appointments 82 80 Practice Practice Practice A B C
  9. 9. Which HC professional would you want to go to? 96 94 92 Patient 90 Satisfaction 88 Accommodated 86 Appointments 84 % of people back 82 to full functioning 80 Practice Practice Practice A B C
  10. 10. Which HC professional would you want to go to? 95 90 Patient Satisfaction 85 Accommodated 80 Appointments % of people back 75 to full functioning Harm-free care 70 Practice Practice Practice A B C
  11. 11. DF
  12. 12. What challenge are we trying to solve?
  13. 13. Current level of HarmUSA 3.7% of admissions 44-98,000 deathsAustralia 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
  14. 14. Q1 25.1 harms per 100 admissions
  15. 15. Global Trigger Tool Reviews 3 Exemplar 40 Bed rural 10 Hospital 7 Hospital Multi-state Hospitals Hospital (300 Research System Tertiary (900 notes) notes) Project (240 (3000 notes) System notes) (2000 notes)Events/1000 83 90 NA 119 86DaysEvents/100 45 40 37 41 38admissionsAdmissions 32% 30% 30% 29% 30%withadverseevents
  16. 16. 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
  17. 17. Q1
  18. 18. Q1 Evidence based medicine  Evidence based care delivery 17 years to get 14% of evidence into practice
  19. 19. How did we set out to solve it?
  20. 20. “quality improvement”The combined and unceasing efforts of everyone – health care professionals, patients and theirfamilies, 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
  21. 21. 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
  22. 22. 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
  23. 23. Q1-6 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?
  24. 24. It‟s complicated….Too bad all the people who know how to run the country are busy driving cabs and cutting hair. -- George Burns
  25. 25. “Conquering the world on horseback is easy: it is dismounting and governing that is hard” Genghis Khan
  26. 26. JL
  27. 27. Q3 IHI Breakthrough Series CollaborativeQ6Select Participants (10-100 teams)Topic(developmission) Prework Develop Dissemination P P P Framework A D A D Publications, A D & Changes Congress. etc.Expert S S SMeeting LS 1 LS 2 Holding Planning LS 3 Group AP1 AP2 AP3* the Gains Supports *AP3 –continue reporting data as LS – Learning Session Email (listserv) Phone Conferences needed to document success AP – Action Period Visits Assessments Monthly Team Reports
  28. 28. Aim Measures Changes ExecutionThe Improvement Guide, API
  29. 29. Q2Q3 How has the frontline done it? • Get goals. • Get the facts. • Get bold. • Get to the field. • Get together. • Get a clock. • Get a model (and • Get the numbers. stick with it) • Get the stories. • Get patients and families
  30. 30. Q2 Outcome AimsQ3 • 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
  31. 31. What can be achieved?
  32. 32. HSMRHospital Standardised Mortality Ratio
  33. 33. Q4 Scotland – 7% reduction in HSMR 1.5 1.3Standardised Mortality Ratio 1.0 0.8 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p
  34. 34. Q4 1.5 1.5 1.3 Standardised Mortality Ratio 1.3 Standardised Mortality Ratio 1.0 1.0 0.8 0.8 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 1.5 1.5Standardised Mortality Ratio 1.3 1.3 Standardised Mortality Ratio 1.0 1.0 0.8 0.8 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- 0.5 Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 1.5 1.5 1.3 Q5 Standardised Mortality Ratio 1.3 Standardised Mortality Ratio 1.0 1.0 0.8 0.8 0.5 0.5 Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010* 2011p HSMR results 2008-2011
  35. 35. Scotland level results
  36. 36. Q4 Central line infection rate (per thousand line days) 12 10 March 2011: zero central line infections 8 in whole country 6 4 2 0 08 09 10 11 8 9 0 1 8 9 0 1 8 9 0 l-0 l-0 l-1 l-1 r- 0 r- 0 r- 1 r- 1 -0 -0 -1 n- n- n- n- ct ct ct Ju Ju Ju Ju Ap Ap Ap Ap Ja Ja Ja Ja O O O
  37. 37. Q4 0 2 4 6 8 10 12 14 16 18 20Jan-08Mar-08May-08 Jul-08 9.11Sep-08Nov-08Jan-09Mar-09May-09 Jul-09Sep-09Nov-09 VAP rateJan-10Mar-10May-10 (per thousand ventilator days) Jul-10Sep-10 62% reductionNov-10Jan-11Mar-11May-11 3.49 Jul-11
  38. 38. Q4 10 12 14 16 18 20 22 24 26 28Jan-08Mar-08May-08 Jul-08Sep-08Nov-08 18.2%Jan-09Mar-09May-09 Jul-09Sep-09Nov-09Jan-10Mar-10May-10 % ICU mortality Jul-10 14% improvementSep-10Nov-10Jan-11Mar-11May-11 15.7% Jul-11
  39. 39. 0.5 1.5 2.5 0 1 2Jan-08 Q4 Q5Mar-08May-08 1.18 Jul-08Sep-08Nov-08Jan-09Mar-09May-09 Jul-09Sep-09Nov-09Jan-10Mar-10May-10 (per thousand patient days) Jul-10Sep-10 88% reductionNov-10 General ward C.Difficile rateJan-11Mar-11 0.14May-11 Jul-11
  40. 40. How has NHSScotland done it? Policy Leadership Execution Structure Process OutcomeDonabedian, A.Explorations in Quality Assessment andMonitoring. Volume I: The Definition of Qualityand Approaches to its Assessment.1980.
  41. 41. Having the bestprofessionals in the world is no longer enough
  42. 42. Q4 The Capacity and Capability Aim To build a sustainable infrastructure that produces highly reliable QI excellence by (fill in the date). How good? By when? © 2010 Institute for Healthcare Improvement
  43. 43. Q4 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 © 2010 Institute for Healthcare Improvement
  44. 44. Q4 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. © 2010 Institute for Healthcare Improvement
  45. 45. DF
  46. 46. Q6 Moving beyond safety
  47. 47. 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
  48. 48. Q2 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.
  49. 49. The 3-step improvement framework forScotland’s public services “Do not be content with mediocrity. Do your job so well that nobody could do it better.” Martin Luther king Jr.
  50. 50. The 3-step Improvement Framework for Scotland’s public services Macro system – 1) Change Vision, aim and context. the world Meso system – Culture, capacity And challenge. How much and by 2) Create the conditions when? Micro system – Implementation, measur3) Make the improvement ement and improvement
  51. 51. Step 1; Changing the world – an evidence base•This is the macro-system‟s role: vision, strategy and building coalitions. “Aimscreate systems” – W. Edwards Deming•It must establish a vision, a theory of reform, an engagement strategy and anunderstanding 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
  52. 52. 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
  53. 53. Step 2; Creating the conditions•This is the meso-system‟s role: Capacity and capability building,•It must communicate the changes, empower the citizens andworkforce, 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?
  54. 54. Step 2; Creating the conditions The public services improvement bundleThe 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/noOnly proceed if all six are yes – all-or-none measurement.
  55. 55. Step 3; Executing the change•This is the micro-system‟s role: all improvement is local.•Will and ideas are not enough at this level – we need execution. We needa theory of change and the ability to test and implement the changes. • 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.
  56. 56. How prepared is your organization?Key Components Self-Assessment • Will (to change) • Low Medium High • Ideas • Low Medium High • Execution • Low Medium High © 2010 Institute for Healthcare Improvement
  57. 57. "Quality is never an accident; it is always the result of high intention, sincereeffort, intelligent direction and skillful execution; itrepresents the wise choice of many alternatives.” 1941, William A. Foster
  58. 58. 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?

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