Methods for Improvement Where is the Will? David I Gozzard Quality Improvement Fellow Health Foundation
IN HEALTHCARE!
Improvement Mantra <ul><li>Will </li></ul><ul><li>Ideas </li></ul><ul><li>Execution </li></ul>… ..then Scrutiny
WILL <ul><li>The mental faculty by which one chooses or decides upon a course of action </li></ul><ul><li>The act of exerc...
Problems around Will <ul><li>Data </li></ul><ul><ul><li>“ Somebody else's data, doesn’t relate to my clinic or practice” <...
Clinician Comments <ul><li>“ Too busy……..admin and over-busy clinical time” </li></ul><ul><li>“ It’s a nursing thing – I j...
Improvement Culture: A Useful Guide “ Every enterprise has four organisations: the one that is written down, the one that ...
The Discomfort Zone Comfort Zone:  People stay here, don’t change, don’t learn Discomfort Zone :  People uncertain, but mo...
The Individual: Readiness to Change Prochaska et al 1992 Descriptor Behaviour Action Pre-contemplation The individual is n...
The Nature of Change Change can be….. Collective Everyone in a group must decide to adopt or not Authoritative The individ...
The Scepticism Continuum behaviour behaviour attitude active   passive  scepticism  neutrality  acceptance  commitment  ac...
The Value of Resistance “ Commercial practice, for example, often interprets resistance to change as a natural and necessa...
The Involvement Conundrum Impact on personal status, patients and the organisation Political considerations Timing Degree ...
Trust Reported Incidents
Errors and harm - are they the same thing? Errors Errors that cause no harm to the patient (Near Misses) Errors that harm ...
Harm <ul><li>Every system is designed to produce the outcome it gets </li></ul><ul><li>We have systems of care designed to...
Errors: <ul><li>Failure of a planned action to be completed as intended </li></ul><ul><ul><li>Error of execution </li></ul...
Adverse Event: <ul><li>Injury caused by medical management rather than the underlying medical condition of the patient </l...
What Could we Measure? <ul><li>Performance management requirements </li></ul><ul><ul><li>Contractual items </li></ul></ul>...
Why are  you measuring? The answer to this question will guide your entire quality measurement journey! Improvement? Judgm...
The Three Faces of Performance Measurement Bob Lloyd, IHI Aspect Improvement Accountability Research Aim Improvement of ca...
Measuring Quality <ul><li>No system in place to measure quality </li></ul><ul><li>What are our quality indicators? </li></...
Hope is Not a Plan
Boards think quality is a lot better than the managers, doctors and nurses do.
Results from NPSF/AIG and Estes Park Survey Definitely Not at all 1 2 3 4 5 How comfortable are you with your level of eng...
Results from NPSF/AIG and Estes Park Survey Definitely Not at all 1 2 3 4 5 Executive  leadership and the board are visibl...
Better Outcomes Are Associated With Hospitals in Which . . . <ul><li>The board spends more than 25% of its time on quality...
Board Stages in Quality  Engaged Capable No Yes No Q is just fine, thanks, and besides, it’s not our problem Frustrated an...
Framework:  Leadership for Improvement Will Ideas Execution Establish the Foundation Setting Direction: Mission, Vision an...
 
The Best Boards… <ul><li>Aim high </li></ul><ul><ul><li>“ Our aim is to achieve zero central line infections…”  </li></ul>...
Mission & Strategy Organisation Objectives Local Objectives Improvement Projects Individual PDP Projects not aligned to or...
The Audit Cycle <ul><li>Consists of… </li></ul><ul><ul><li>Observation of existing practice </li></ul></ul><ul><ul><li>The...
Audit and Improvement ©National Leadership and Innovation Agency for Healthcare  Asiantaeth Genedlaethol Arweiniad ac Arlo...
A True Measure of a QI Programme
The Lessons of  Jönköping
Sweden Jönköping county Europe
Jönköping  County Council is responsible for the public health care services 160 new patients staying over night at the ho...
The Esther Project “ Esther” is not a real patient but her persona as a grey-haired, ailing, but competent elderly Swedish...
Objectives of Esther Project <ul><li>Security for Esther </li></ul><ul><li>Better working relationships in the entire care...
Projects to support Esther <ul><li>Develop flexible organisation with patient value in focus </li></ul><ul><li>Design more...
The Inspiration of Esther Improvements 1998 2003 Hospital Admissions 9,300 7,300 Hospital Days for CHF 3,500 2,500 (yr 200...
 
Patient focused “ Activities and sub processes organised after prioritised patient values” Patient  ask for Primary Care E...
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The art of the possible will

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  • Unquestioning compliance with reform is interpreted as being incompatible with the development of grass-roots ownership of change.
  • The findings also demonstrate that individuals’ acceptance of change is affected by a complex and connected set of social and organisational factors, including the nature of the change itself as well as issues of context and timing. These powerful influences on decision making are summarised in the figure above. They represent a conundrum for those who are considering change but are not convinced of its value. How are those factors perceived and weighted in terms of significance and priority with regard to shaping the individual’s ultimate decision and the timing of that outcome?
  • The art of the possible will

    1. 1. Methods for Improvement Where is the Will? David I Gozzard Quality Improvement Fellow Health Foundation
    2. 2. IN HEALTHCARE!
    3. 3. Improvement Mantra <ul><li>Will </li></ul><ul><li>Ideas </li></ul><ul><li>Execution </li></ul>… ..then Scrutiny
    4. 4. WILL <ul><li>The mental faculty by which one chooses or decides upon a course of action </li></ul><ul><li>The act of exercising the will </li></ul><ul><li>Diligent purposefulness; Determination </li></ul><ul><li>Self-control; Self-discipline </li></ul><ul><li>A desire, purpose or determination, especially one in authority </li></ul><ul><li>Free discretion, inclination or pleasure </li></ul><ul><li>Bearing or attitude towards others; disposition </li></ul>
    5. 5. Problems around Will <ul><li>Data </li></ul><ul><ul><li>“ Somebody else's data, doesn’t relate to my clinic or practice” </li></ul></ul><ul><li>Discomfort </li></ul><ul><ul><li>“ Discomfort Zone” </li></ul></ul><ul><li>Denial/Disbelief </li></ul><ul><ul><li>“ Nothing wrong with my practice” </li></ul></ul><ul><ul><li>“ It’s the uniqueness of my patients” </li></ul></ul>
    6. 6. Clinician Comments <ul><li>“ Too busy……..admin and over-busy clinical time” </li></ul><ul><li>“ It’s a nursing thing – I just deal with my own patients” </li></ul><ul><li>“ Quality suffers because of the outliers, lack of junior staff, the lack of continuity – SPI is just around the margins” </li></ul><ul><li>“ I am not paid to do this” </li></ul><ul><li>“ My cases are high quality – it’s the other ward that is dirty” </li></ul><ul><li>“ Things are not like they used to be - we used to work harder and be more vigilant” </li></ul><ul><li>“ No clear vision from Government – yet another initiative” </li></ul><ul><li>“ It’s not in the targets set by my General manager” </li></ul><ul><li>“ I don’t believe the data” </li></ul><ul><li>“ You have gone over to the dark side” </li></ul>
    7. 7. Improvement Culture: A Useful Guide “ Every enterprise has four organisations: the one that is written down, the one that most people believe exists, the one that people wished existed and finally, the one that the organisation really needs” NHS Chief Executive
    8. 8. The Discomfort Zone Comfort Zone: People stay here, don’t change, don’t learn Discomfort Zone : People uncertain, but most likely to change, most likely to learn Panic Zone: People freeze, will not change, will not learn To encourage people to leave a comfort zone, you need to help them feel safe. You can do this by creating the right environment and culture, ensuring that there is no blame. 
    9. 9. The Individual: Readiness to Change Prochaska et al 1992 Descriptor Behaviour Action Pre-contemplation The individual is not ready to discuss or consider change Consciousness raising Contemplation The individual is willing to listen and to consider a change Emphasis on benefits Preparation The individual gets ready to do something concrete Provide support Action The individual starts to work with the change Continue support in addition to encouragement and praise Maintenance The individual strives not to slip back to old behaviours Scrutiny of process?
    10. 10. The Nature of Change Change can be….. Collective Everyone in a group must decide to adopt or not Authoritative The individual is told to adopt Contingent The individual cannot choose to adopt until the organisation has sanctioned it
    11. 11. The Scepticism Continuum behaviour behaviour attitude active passive scepticism neutrality acceptance commitment active resistance resistance involvement Scepticism : The questioning or doubting of accepted opinion Resistance : Through actions and arguments prevent someone from doing something, or prevent something from happening
    12. 12. The Value of Resistance “ Commercial practice, for example, often interprets resistance to change as a natural and necessary force for exposing and resolving conflict, and consequently for planning and implementing change effectively. “ Organisations need resistance to change in order to prevent bad and poorly developed ideas from being implemented. Mabin et al 2001 Schön 1963
    13. 13. The Involvement Conundrum Impact on personal status, patients and the organisation Political considerations Timing Degree of information or understanding Complexity Impact Skills required Priority Source Focus The individual contemplating change The proposed change Time Context
    14. 14. Trust Reported Incidents
    15. 15. Errors and harm - are they the same thing? Errors Errors that cause no harm to the patient (Near Misses) Errors that harm the patient Harm Harm caused by “normal care”
    16. 16. Harm <ul><li>Every system is designed to produce the outcome it gets </li></ul><ul><li>We have systems of care designed to produce certain levels of harm </li></ul><ul><li>These levels of harm have become acceptable as a property of the system </li></ul><ul><li>All harm is theoretically preventable </li></ul>
    17. 17. Errors: <ul><li>Failure of a planned action to be completed as intended </li></ul><ul><ul><li>Error of execution </li></ul></ul><ul><li>Use of a wrong plan to achieve an aim </li></ul><ul><ul><li>Error of planning </li></ul></ul>
    18. 18. Adverse Event: <ul><li>Injury caused by medical management rather than the underlying medical condition of the patient </li></ul><ul><li>Adverse event caused by error is an……. </li></ul><ul><li>AVOIDABLE ADVERSE EVENT </li></ul>
    19. 19. What Could we Measure? <ul><li>Performance management requirements </li></ul><ul><ul><li>Contractual items </li></ul></ul><ul><ul><li>Number of patients </li></ul></ul><ul><ul><li>Patient episodes </li></ul></ul><ul><ul><li>Trends in attendances </li></ul></ul><ul><ul><li>Waiting times </li></ul></ul><ul><li>Number of critical incidents </li></ul><ul><ul><li>Incident reporting and categorisation </li></ul></ul>No link here
    20. 20. Why are you measuring? The answer to this question will guide your entire quality measurement journey! Improvement? Judgment? Research?
    21. 21. The Three Faces of Performance Measurement Bob Lloyd, IHI Aspect Improvement Accountability Research Aim Improvement of care Comparison, choice, reassurance New knowledge Methods: Test Observability Tests are observable No test; merely evaluate current performance Test blinded or controlled tests Bias Accept consistent bias Measure and adjust to reduce bias Design to eliminate bias Sample Size “ Just enough” data, small sequential samples Obtain 100% of available, relevant data “ Just in case” data Flexibility of Hypothesis Hypothesis flexible, changes with learning No hypothesis Fixed hypothesis Testing Strategy Sequential tests No tests One large test Determining if change is an imrovement Run charts or Shewhart control charts No change focus Hypothesis, statistical tests Confidentiality of the Data Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected
    22. 22. Measuring Quality <ul><li>No system in place to measure quality </li></ul><ul><li>What are our quality indicators? </li></ul><ul><ul><li>Data for performance management </li></ul></ul><ul><ul><li>Data for research </li></ul></ul><ul><ul><li>Data for quality improvement </li></ul></ul><ul><li>40 “measures” </li></ul><ul><ul><li>Each required a new system to measure </li></ul></ul><ul><ul><li>Mostly via laborious case note audit </li></ul></ul><ul><ul><ul><li>But it had to be done! </li></ul></ul></ul>
    23. 23. Hope is Not a Plan
    24. 24. Boards think quality is a lot better than the managers, doctors and nurses do.
    25. 25. Results from NPSF/AIG and Estes Park Survey Definitely Not at all 1 2 3 4 5 How comfortable are you with your level of engagement safety? 9 37 32 14 7 % Mgmt 4 42 46 6 2 % Board C-Suite Does patient safety trump productivity in your work organization?   9 18 41 20 12 % Mgmt 40 34 20 4 2 % Board C-Suite Are you able to engage your staff in patient safety activities?   13 31 41 13 0 % Mgmt 41 45 12 2 0 % Board C-Suite
    26. 26. Results from NPSF/AIG and Estes Park Survey Definitely Not at all 1 2 3 4 5 Executive leadership and the board are visibly engaged in patient safety   10 31 36 15 8 % Mgmt 19 65 14 1 1 % Board C-Suite Executive leadership provides the tools and training to be effective     9 30 37 17 7 % Mgmt 14 58 25 2 1 % Board C-Suite Physician leadership is actively engaged in patient safety efforts   5 18 33 31 12 % Mgmt 20 48 26 5 1 % Board C-Suite
    27. 27. Better Outcomes Are Associated With Hospitals in Which . . . <ul><li>The board spends more than 25% of its time on quality issues. </li></ul><ul><li>The board receives a formal quality performance measurement report. </li></ul><ul><li>There is a high level of interaction between the board and the medical staff on quality strategy. </li></ul><ul><li>The senior executives’ compensation is based in part on QI performance. </li></ul><ul><li>The CEO is identified as the person with the greatest impact on QI, especially when so identified by the QI Executive. </li></ul>Vaughn T, Koepke M, Kroch et. al. 2006
    28. 28. Board Stages in Quality Engaged Capable No Yes No Q is just fine, thanks, and besides, it’s not our problem Frustrated and confused about how Yes If we could only light the fire… How do we do this even better?
    29. 29. Framework: Leadership for Improvement Will Ideas Execution Establish the Foundation Setting Direction: Mission, Vision and Strategy PULL PUSH Changing the old Making the future attractive
    30. 31. The Best Boards… <ul><li>Aim high </li></ul><ul><ul><li>“ Our aim is to achieve zero central line infections…” </li></ul></ul><ul><li>Aim broad </li></ul><ul><ul><li>“… for the entire institution, across all services…” </li></ul></ul><ul><li>Take dead aim </li></ul><ul><ul><li>“… by August 31, 2009.” </li></ul></ul>
    31. 32. Mission & Strategy Organisation Objectives Local Objectives Improvement Projects Individual PDP Projects not aligned to organisation objectives are doomed to failure as senior staff will have no interest in their outcome
    32. 33. The Audit Cycle <ul><li>Consists of… </li></ul><ul><ul><li>Observation of existing practice </li></ul></ul><ul><ul><li>The setting of standards </li></ul></ul><ul><ul><li>Comparison between observed and set standards </li></ul></ul><ul><ul><li>Implementation of change </li></ul></ul><ul><ul><li>Re-audit of clinical practice </li></ul></ul>
    33. 34. Audit and Improvement ©National Leadership and Innovation Agency for Healthcare Asiantaeth Genedlaethol Arweiniad ac Arloesoldeb dros Ofal Iechyd Improvement project Audit Audit Audit as Initiator and Scrutiny Prototype Pilot Adapt and Spread
    34. 35. A True Measure of a QI Programme
    35. 36. The Lessons of Jönköping
    36. 37. Sweden Jönköping county Europe
    37. 38. Jönköping County Council is responsible for the public health care services 160 new patients staying over night at the hospitals/day 9 newborns/day 3 Hospitals 34 Primary care centers 9,500 employees 350,000 inhabitants 6.100 visits per day 1.500 visit a specialist/day 1.300 visit to GP/day (300 visits to private doctors/day) Jönköping Höglandet Värnamo
    38. 39. The Esther Project “ Esther” is not a real patient but her persona as a grey-haired, ailing, but competent elderly Swedish woman with a chronic condition and occasional acute needs has inspired impressive improvement in how patients flow through a complex network of providers and care settings in Höglandet, Sweden “ What is best for Esther?”
    39. 40. Objectives of Esther Project <ul><li>Security for Esther </li></ul><ul><li>Better working relationships in the entire care chain </li></ul><ul><li>Higher competence through the care chain </li></ul><ul><li>Shared medical documentation </li></ul><ul><li>Quality through the entire care chain </li></ul><ul><li>Documentation and communication of improvements </li></ul>
    40. 41. Projects to support Esther <ul><li>Develop flexible organisation with patient value in focus </li></ul><ul><li>Design more efficient and improved prescription and medication routines </li></ul><ul><li>Create ways in which documentation and communication of information can be adapted to the next link on care chain </li></ul><ul><li>Develop an efficient IT-support through whole care chain </li></ul><ul><li>Develop and introduce a diagnosis system for community care </li></ul><ul><li>Develop a virtual competence centre for better transfer and improvement of competence through the care chain </li></ul>
    41. 42. The Inspiration of Esther Improvements 1998 2003 Hospital Admissions 9,300 7,300 Hospital Days for CHF 3,500 2,500 (yr 2000) Waiting times to see a neurologist 85d 14d Waiting times to see a gastroenterologist 48d 14d
    42. 44. Patient focused “ Activities and sub processes organised after prioritised patient values” Patient ask for Primary Care Examination primary care treatment Hospital Diagnosis & decision on treatment Prim.C/ Hospital Rehabilitation Primary Care Treatment Hospital Rehabilitation Municipality/ Community Care Esther Six Primary care units Rehab ER Medicine Hospital in the town Eksjö Six municipalities Traditional “ Functional&quot; Lab Pharmacy From a Functional to a Patient Oriented Healthcare Organisation Patient treatment finished Patient with disease

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