Quality improvement programme launch event slides


Published on

Quality improvement programme at East London NHS Foundation Trust

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • The PDSA cycle is a tool we use to distinguish changes that are effective from those that are not so that we can concentrate our efforts
  • Four parts of the cycle:
    Decide what change you will make, who will do it, and when it will be done. Formulate an hypothesis about what you think will happen when you try the change. What do you expect will happen?
    Identify data that you can collect (either quantitative or qualitative) that will allow you to evaluate the result of the test.
    Carry out the change.
    Make sure that you leave time for reflection about your test. Use the data and the experience of those carrying out the test to discuss what happened. Did you get the results you expected? If not, why not? Did anything unexpected happen during the test?
    Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale?
  • References:
    1. Accelerating the pace of improvement: interview with Thomas Nolan. Journal of Quality Improvement. 1997;23(4).
    2. Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312:619-622.
    3. Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996.
    4. Lloyd R. Quality Health Care: A Guide to Developing and Using Indicators. Sudbury, MA: Jones and Bartlett Publishers; 2004.
    5. Moen R, Nolan T, Provost L. Quality Improvement Through Planned Experimentation. 2nd ed. New York, NY: McGraw-Hill Companies; 1998.
    6. The Improvement Handbook. Austin, TX: Associates in Process Improvement; 2005.
  • Design tips - narrative
    Always consider your audience, who are they, what do they expect, how much will they know, what are the key messages they need to take away?
    Tell a story - have a beginning a middle and an end.
    Slides should follow a natural progression.
    Remember the three times rule - tell your audience what you are going to tell them, tell it, and then summarise it.
     Design tips – colour and images
    Avoid using all the available colours. Blue is always our core colour, try not to use more than 2 secondary colours from the palette and only one secondary colour can be used on any given slide.
    Use images carefully. They should help the audience relate slide information to real world situations. Always ensure good legibility is maintained when text is placed over images.
    Do not use clipart.
    Use graphics after careful consideration. Only use them if it adds to the communication.
    Additional logos – for partners or other parties you co-present with – please place the logo in the bottom right hand corner
  • Quality improvement programme launch event slides

    1. 1. Quality Improvement Programme Launch Event
    2. 2. Our quality improvement programme Why?
    3. 3. The strategic case for change
    4. 4. Changing the culture through quality improvement Involvement of service users and carers through every step of the journey
    5. 5. The culture we want to nurture
    6. 6. Our quality improvement programme How?
    7. 7. Two stretch aims Reduce harm by 30% every year Right care, right place, right time Quality improvement strategy Long-term mission and stretch aims The mission To provide the highest quality mental health and community care in England by 2020
    8. 8. Long-term mission and stretch aims
    9. 9. Long-term mission and stretch aims
    10. 10. Make-up Functions Programme director (Medical Director) Coordinate the programme Improvement expertise to support frontline work Learning and sharing – internally & externally Deputy programme director (Associate Medical Director) Programme manager Continuous improvement and measurement lead 2 x rotating clinical secondments Programme support Long-term mission and stretch aims Central QI team
    11. 11. Traditional engagement • Launch event & roadshows • Through formal directorate structures • Local champions Grassroots movement / campaign • Q30 (staff) and Q12 (service user) groups to shape our comms • Microsite – as a central resource • Branding & identity Long-term mission and stretch aims Central QI team Building the will
    12. 12. Financial measures Clinical audit Real-time patient experience feedback Learning from complaints Stopping activity of lower value Influencing contracts and CQUINs Datix improvements Reviewing our inductions Integrated quality data available to all Embedding a structure for listening Outcome measures Long-term mission and stretch aims Central QI team Building the will Aligning our systems
    13. 13. Successful improvement requires a specific set of skills Appointment of an external partner to build skills within our workforce at scale & pace Most of us have not been trained in improvement Improvement at scale needs a consistent approach Long-term mission and stretch aims Central QI team Building the will Aligning our systems Building improvement skills
    14. 14. Quality Improvement in Action
    15. 15. Anticipating and Reducing Violence at the Tower Hamlets Centre for Mental Health
    16. 16. Violence: The Background • National Problem: NHS reported 59,744 violent incidents during 2012 • Incidents 3 times more likely to occur in mental health services • 3710 reported incidents of violence and aggression in ELFT in 2013
    17. 17. Our Work: The context • Serious incident on Roman Ward, April 2010, highlighted huge problems in care at THCfMH. • Since then significant improvements in many areas, including leadership, environment, staffing, MDT working and culture. • Actual rates of violence in 2010, probably significantly higher than reported on Datix (estimated >50%) • Staff Feedback surveys indicate that violence is a major issue for our staff.
    18. 18. The Plan May 2012 Reducing Violence Strategy The Tower Hamlets DMT made a decision to really focus on reducing violence on our wards. Strategy had various action points including: Smoking balconies Smoother pathways to PICU’s Bed Occupancy Regular team away days Improved Police Liaison Commissioning Psychology to do analysis of one months incidents More activities Out of Hours Safety crosses Introduction of the Broset Risk Assessment on Globe Ward Most of all we were trying to change to a culture which sees violence as the unacceptable exception rather that the norm.
    19. 19. Team Reaction 1. The simplicity of the BVC made it very attractive. 2. Teething problems, especially around the idea that in a PDSA cycle the change needs to be done reliably and consistently (this was hard to embed in practice initially) 3. The importance of then ensuring that a BVC score > 2 triggered a team discussion (mid-flight briefing / ‘huddle’) 4. The importance of MDT involvement / flattening the hierarchy
    20. 20. The Results
    21. 21. Reducing Harm from Pressure Ulcers
    22. 22. Pressure Ulcers • Anyone can get a pressure ulcer • Pressure ulcers are in most cases preventable • Key quality indicator of care • National CQUIN target
    23. 23. Extent of the Problem • 4%-10% incidence depending on speciality • Immobile and elderly most affected • ELFT: Total of 285 reported in 2012/2013 of which 87 were acquired in our care (N= 24 grade 3/4)
    24. 24. Patient Impact: John • • • • • • • 3 72 year old gentleman Living independently Fall and fractured femur Developed a pressure ulcer Pain, immobility, social isolation Loss of independence Timely recovery with input from the tissue viability service
    25. 25. Financial Impact • Accounts for £4 billion per year - 4% of total NHS expenditure • Poor quality care costs more – High Impact Actions ‘Your skin matters’ • Pressure ulcers acquired in ELFT for 2012/2013 estimated cost of £541,000 to treat
    26. 26. April 2013 • 5 grade 3&4 pressure ulcers • Pressure ulcer training & competency framework for relevant staff • Secondment of TVN to EPCT in July 2013 • Launch of SSKIN bundle in October 2013
    27. 27. SSKIN Bundle-Preventing Pressure Ulcers Surface S Static foam / alternating pressure relieving mattress Mattress calibrated to correct weight of patient if required Pressure relieving cushion Wheelchair / cushion Repose boot / pillow / Aderma dermal pad Patient education on use of equipment Skin Inspection S Skin assessment Teach carers / family Shared Care Approach to Pressure Ulcer Prevention SSKIN Bundle Guidelines for Staff Keep Moving K Regular repositioning 2 hourly or at each visit by the carers Incontinence/ Moisture I Continence assessment / management Catheter Bowels Incontinent pads Barrier cream General skin care Nutrition N Nutritional assessment Eating & drinking Nutritional supplements / thickened fluid
    28. 28. Incidents Per Quarter Patients with Grade 3&4 Pressure Ulcers Acquired in our Care (2013-2014) Q1 10 Q2 5 Q3 3 Q4 3 in January alone
    29. 29. A Different Picture? Frontline staff support and competency assessments TVN Secondment QI methodology Use of outcome, process and balance measures Launch of SKINN bundle
    30. 30. Using the QI Approach • We identified a number of processes essential to reducing Pressure Ulcers • Little and often audits • Surprising variation revealed • % completion of risk assessment within 6 hours. Variation from 100% to 16% between different teams within ELFT
    31. 31. Old Way versus the New Way Old Way (Quality Assurance) New Way (Quality Improvement)
    32. 32. Conclusion • Pressure ulcers are mostly avoidable • Prevention requires a different whole system approach • About using and acting on the right data at the right time
    33. 33. Methodology How do we deliver a consistent approach to quality?
    34. 34. Partnering with an external organisation Why do we need an external partner? What will they bring? •Build improvement skills at scale and at pace over the first 2 years •Strategic support • How to deliver large-scale sustainable and successful improvement • Methodology, tools and techniques – and ensuring fidelity • Critical friend
    35. 35. Introduction to our external partner
    36. 36. Independent, not-for-profit organisation Based in Cambridge, Massachusetts Leading innovator, convenor, partner and driver of results in health and healthcare worldwide 5 key areas of work • • • • • Improvement capability Patient and family-centred care Patient safety Quality, cost and value Triple aim for populations (improving health outcomes, experience and per capita cost)
    37. 37. Let’s hear from the leaders at IHI
    38. 38. Model for Improvement & its impact within a clinical team
    39. 39. The Model for Improvement
    40. 40. Improving quality of care on an inpatient female psychiatric ward AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS
    41. 41. The PDSA Cycle “What’s next? ” “Did it work?” “What will happen if we try something different?” “Let’s try it!”
    42. 42. You need a team • Why? – Need different perspectives – It’s a lot of work – Increased buy-in by staff – Different levels of support (e.g. management) • To come up with the right team you have to have an idea of what your aim is…
    43. 43. The Aim • A strong, measurable aim with a clear time frame will help keep your project on course • It has to be important to those involved
    44. 44. The Steps to Change Make part of routine operations Test under a variety of conditions Theory and Prediction Develop a change Test a change Implement a change Spread to other sites / groups / popn
    45. 45. How to implement Quality Improvement into Practice • Clear overall objective is Improving patient experience • Gaining service user feedback in a timely meaningful manner – issues could be acted upon immediately • Use of tablets every two weeks – engaging staff members in the process – used initially on Connolly and Gardner ward included both qualitative and quantitative information.
    46. 46. Service User Feedback 1 2 3 4 No, I had lots of problems No I had some problems Yes, to some extent Yes, definitely a. b. c. d. e. f. N/A Did you have trust and confidence in the professional that saw you today? Did the person treat you with respect and dignity? Did this person give you information you could understand about your care , treatment and condition? When you had important questions to ask did this person, did you get answers you could understand? Were you involved as much as you wanted to be in decisions regarding your care and treatment today? Friends and family test : How Likely are you to recommend our ward/service to friends and family if they need similar care or treatment
    47. 47. How to implement Quality Improvement into Practice • • • • • • • • Direct link with patient experience and bed pressures Changes to the weekly bed management meetings Inclusion of all clinical teams, including inpatient Nursing staff, Consultants, HTT , Community leads, Welfare Rights lead, Housing Lead and Social care staff. Initially concentrated on the list of patients who were classified as a delayed discharge. Looked at all new admissions – early identification of social needs Long length of stay patients – care planning Made individuals take ownership for specific actions. Support and advice regarding legal issues, risk issues and accommodation options.
    48. 48. Measurement and Using Data for Improvement
    49. 49. Service user experience Blood results MMSE Waiting lists Clinical Trials and Research How Do ELFT Use Measurement? Service user outcomes BPRS CQUINS & KPIs
    50. 50. The Three Faces of Measurement • Research (efficacy) • Improvement (efficiency and effectiveness) • Accountability (reassurance, comparison)
    51. 51. Research Aim New Knowledge (efficacy) Methods: Test observability Tests are blinded or controlled Bias Designed to eliminate bias Sample size ‘Just in case data’ (very large data sets) Flexibility of hypothesis Fixed hypothesis Testing Strategy One large test Determining if a change is an improvement Enumerative Statistics (t-test, p-values)
    52. 52. Improvement Aim Improvement of care (efficiency and effectiveness) Methods: Test observability Tests are observable Bias Accept consistent bias Sample size ‘Just enough data’, small sequential samples Flexibility of hypothesis Flexible and changes as learning takes place Testing Strategy Sequential test over time Determining if a change is an improvement Analytical statistics. Run and Control charts
    53. 53. Accountability Aim Comparison, choice, reassurance, motivation for change Methods: Test observability No test, evaluate current performance Bias Measure and adjust to reduce bias Sample size Obtain 100% of available, relevant data Flexibility of hypothesis No hypothesis Testing Strategy No tests Determining if a change is an improvement No change focus
    54. 54. The Three Faces of Measurement • Research (efficacy) • Improvement (efficiency and effectiveness) • Accountability (reassurance, comparison)
    55. 55. Does this represent improvement? 1.Yes 2. No
    56. 56. Why Measure? • How can you tell if you are improving? • Data collection and analysis are central to QI • Helps identify quality problems but also opportunities for improvement • Allows us to track improvement over time • Success of programme will hinge on the measurements we put in place
    57. 57. Spread
    58. 58. Our challenge
    59. 59. The seven spreadly sins If you do these things, spread efforts will fail… 1. 2. 3. 4. 5. Start with large pilots Find one person willing to do it all Expect vigilance and hard work to solve the problem If a pilot works, then spread the pilot unchanged Require the person and team who drove the pilot to be responsible for system-wide spread 6. Look at process and outcome measures on a quarterly basis 7. Early on expect marked improvement in outcomes with attention to process reliability Have you been at the receiving end of a ‘spreadly sin’? 1. Yes 2. No
    60. 60. The Steps To Change Make part of routine operations Test under a variety of conditions Theory and Prediction Develop a change Test a change Implement a change Spread to other sites / groups / popn
    61. 61. So how do we spread successfully? IHI (2009) A Framework for Spread: From local improvements to system-wide change
    62. 62. So how do we spread successfully? Be patient…
    63. 63. BMJ Quality and East London NHS Foundation Trust Dr Mobasher Butt, Clinical Lead for Quality, BMJ
    64. 64. The challenge Make healthcare improvement simple
    65. 65. What is the BMJ Quality Improvement Programme? An online platform which supports individuals, teams and organisations to work through healthcare improvement projects and onto publication by providing the necessary framework and tools to make healthcare improvement simple.
    66. 66. 5 steps for QI 1. Help identify area for improvement 2. Find out how others have solved it – and what didn’t work 3. Support step-by-step through the improvement process 4. Get advice from mentors, experts and the global community 5. Publish and share your work
    67. 67. 1. WORKBOOK
    68. 68. Learning modules • • • • • • • • • • • Systems Introduction to Patient Safety Human Factors Intervention Design Model for improvement Bringing about Change Using measurement for change Measurement for QI Teamwork Clinical Leadership Stakeholder Relations
    69. 69. Additional materials: • • • • • • • 1) Process Flow Template 2) PDSA Cycle Template 3) Cost Saving Calculator 4) Vancouver Reference guide link 5) BMJ House Style guide 6) ICMJE guideline link 7) QR code generator for Posters
    70. 70. Videos: • • • • • • • • 1) Creativity video 2) Ideas and Inspiration video 3) Functions and Navigation of My Dashboard 4) My Dashboard overview 5) Creating a project 6) Selecting a Mentor and Team members 7) Using the message board 8) Completing and Submitting
    72. 72. 4. JOURNAL
    74. 74. Working together..... • Inspire • Innovate • Improve • Share
    75. 75. How to start an improvement project
    76. 76. qi.eastlondon.nhs.uk
    77. 77. Key Ingredients for Success
    78. 78. Complete Project Charter • Email to QI team • qi@eastlondon.nhs.uk • QI team will get in contact in a few days
    79. 79. The QI Team Will… • Make sure you have right ingredients for success • Help finalise charter • Make sure your project aligns with programme aims • Link you with support on project and methodology • Provide support and access to BMJ Quality platform
    80. 80. What Next for the Programme? • Roadshows: Engage as many of our remaining 3,500 staff • IHI Open School programme available to all staff • Face to face training for 200 staff in next year
    81. 81. Summary and Close