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Vital signs – making measures matter
Transforming End of Life Care 
in Acute Hospitals
Sean Manning
18th November 2015
The black hole?
“We call our measures board the 
‘wall of shame’”
“ Most of what we collect seems 
meaningless to us. We r...
Insights into
• Importance of measurement
• Traditions of measurement
• Knowing How We are Doing
• Pareto principle
• Stru...
Hitting the target but
missing the point!
Measurement for improvement
UnderstandUnderstand
ImproveImprove
MotivateMotivate
Curiosity
“I can make the last stage of
my life as good as possible
because everyone works together
confidently, honestly and
consis...
The traditions of measurement
• eg A‐B comparison, average, huge dataset
Research
• eg one‐to‐many benchmarking 
comparisi...
Research Judgement Improvement
Goal
New knowledge (not its 
applicability)
Comparison
Reward / punishment
Spur for change
...
What mind sets are
at play here?
Research
Improvement
Judgement
What do we collect now?
What does a great team meeting look like?
Is that what we do?
SMART goals
Making better decisions about priorities
Focusing your effort where it matters
Prioritisation - The Pareto Principle
The Principle
We don’t have time to improve everything
A small number of issues account for the majority of the 
challenge...
What does it look like?
Interruptions in surgeries
Tally by GPs of the causes of interruptions while with a patient.
Categ...
What does it look like?
Interruptions in surgeries
Tally by GPs of the causes of interruptions 
while seeing patients.
Cat...
What does it look like?
0
10
20
30
40
50
60
70
80
90
100
0
5
10
15
20
25
30
35
40
45
% of Total
Cumulative %
What does it look like?
0
10
20
30
40
50
60
70
80
90
100
0
5
10
15
20
25
30
35
40
45
% of Total
Cumulative %
Three categor...
What to measure?
Structure Process Outcome
Avedis Donabedian
‘Outcomes remain the ultimate validators of the 
effectivenes...
What to measure?
Structure Process Outcome
o Outcomes are a worthy goal
o All have pros & cons
o Should measure a selectio...
What to measure?
Structure Process Outcome
“Intermediate outcomes”
• a common solution
• properties of both process & outc...
OUTPUTS
HUMAN 
FACTORS
HUMAN
FACTORS
INTERNAL PROCESSES & PROCECEDURES
INPUTSEXTERNAL
FACTORS
Process Measure(s)
Outcome 
...
Metrics for different audiences
Board
Service managers
Project managers
Frontline staff
Focus on
outcome
Focus on
process
...
Driver Diagrams
Benefits ...
build complex strategy
immediate
visual
Different scenarios ...
1. Help generate change ideas...
Aim
Defect Free
Surgery
Avoid 
Mistakes
Avoid
Complications
Avoid
Delays
Driver Intervention
Conduct team brief
Conduct te...
AIM –
an 
improved 
system
Primary driver 1
Primary driver 2
How much? 
By when?
Secondary driver 1
Secondary driver 2
Sec...
Driver Diagrams
Weight loss example
Pedometer
Gym work out 3
days
Squash weekends
No pub weekdays
Take packed
lunch
Low fa...
AIM
Improve
access
Help marshal change ideas
Waiting room info, list clinician interests/languages, web info, Rx access 
(...
AIM PRIMARY
DRIVERS
SECONDARY
DRIVERS
CHANGE
PROJECTS
Improve
access
Doctors (capacity)
Demand
Dealing (efficiency)
Appt s...
AIM PRIMARY
DRIVERS
SECONDARY
DRIVERS
CHANGE
PROJECTS
Improve
access
Doctors (capacity)
Demand
Dealing (efficiency)
Appt s...
Adapted from the Transform National Steering Group 2011, with input from the NHS 
Institute for Innovation and Improvement
How much?
By when?
Different audiences
Board
Service managers
Project managers
Frontline staff
What to measure?
AIM –
an 
improved 
system
Primary driver 1
Primary driver 2
Secondary driver 1
Secondary driver 2
Second...
What to measure?
Add metrics to your driver diagram
Structure Process Outcome Balance
How much?
By when?
What is our basel...
How much & how often?
There is no precise science to guide decisions about how 
many metrics to use, or how often…
How man...
The usual approach
Meeting rooms
Real world
Approve 
Design Design Design Design
Implement !
Courtesy of Patient Safety First
Opinion
Meeting rooms
Real world
Courtesy of Patient Safety First
Implement  
Approve 
Test & 
refine
Test & 
refine
Test & 
refin...
Change through small steps
Change ...
• with a clear purpose
• you can learn from (without fear of failure)
• which is les...
What are we trying to accomplish?
How will we know that change is an improvement?
What change can we make that will result...
Plan-Do-Study-Act
disciplined framework ensures every part is done every 
time
Plan-Do-Study-Act
facilitates rapid prototyping and 
rolling out of new ideas
Plan-Do-Study-Act
“We’re pressed for time, so we’ll be
jumping to conclusions”
We’re pressed for time, so we’ll 
be jumping to conclusions
The Manager’s Dilemma
In order to manage a system, we are required to make predictions
about its future.
How do you look at your data ?
“If I stick my right foot in a bucket
of boiling water and my left foot in
a bucket of ice water, on the
average, I’m pret...
The Problem
Aggregated data presented in
tabular formats or with summary
statistics, will not help you measure
the impact ...
Enumerative Dynamic
Did things improve?
What will happen next?
Should we do something?
Smoking Cessation :Percentage of smokers who
have quit ...
1C-58
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
10/3/2007
10/17/2007
10/31/2007
11/14/2007
11/28/2007
12/12/2007
12/26/...
Protocol
introduced
Letter
from
Clinical
Director
Pharmacy
included
% surgical patients receiving Prophylactic Antibiotics...
Waiting time results
70
35
0
10
20
30
40
50
60
70
80
Avg
Before
Change
Avg After
Change
WaitTime(min.)
Waiting time results 0
10
20
30
40
50
60
70
80
90
100
date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Change
Made
Cyc...
If We Have 3 Numbers in Sequence:
How Do You Report These?
Downward Trend
Upward Trend
Some Recovery
Setback
Collapse
Dram...
Run Charts
Plot the dots
0
10
20
30
40
50
60
70
80
90
100
date
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Change
Made...
0
20
40
60
80
100
120
Consecutive trips
Min.
My Trip To Work
Mean
Common
Cause
Special
Cause
Statistical Process Control
(SPC) Charts:
No of Admissions
0
200
150
100
50
250
Performance Report – Number of Admissions
...
It is normal
to have some variation
But some may be
‘special’
Control charts
2 Ways To Improve A Process
If controlled variation (Common Cause)
• process is stable
• variation is inherent to process
...
7 steps to measurement
https://www.youtube.com/watch?v=Za1o77jAnbw&list=PL_V1d0Y94nv4u2yCCDnApxa
9ykKmSG1oE
Insights into
• Importance of measurement
• Traditions of measurement
• Knowing How We are Doing
• Pareto principle
• Stru...
What do you need from your data?
Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things ar...
Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things ar...
Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things ar...
Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things ar...
Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things ar...
Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things ar...
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Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things are going and how to make it better’

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Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things are going and how to make it better’ presented by Sean Manning, NHS England

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Transforming End of Life Care in Acute Hospitals PM Workshop 3: Vital Signs ‘Making Measurement Better’ How well things are going and how to make it better’

  1. 1. Vital signs – making measures matter Transforming End of Life Care  in Acute Hospitals Sean Manning 18th November 2015
  2. 2. The black hole? “We call our measures board the  ‘wall of shame’” “ Most of what we collect seems  meaningless to us. We rarely see the  results of what we submit.” This paperwork is stopping us doing  our job!”
  3. 3. Insights into • Importance of measurement • Traditions of measurement • Knowing How We are Doing • Pareto principle • Structure ‐ process ‐ outcome measures • Driver diagrams • Model for improvement • Tracking variation • 7 steps to measurement
  4. 4. Hitting the target but missing the point!
  5. 5. Measurement for improvement UnderstandUnderstand ImproveImprove MotivateMotivate Curiosity
  6. 6. “I can make the last stage of my life as good as possible because everyone works together confidently, honestly and consistently to help me and the people who are important to me, including my carer(s).”
  7. 7. The traditions of measurement • eg A‐B comparison, average, huge dataset Research • eg one‐to‐many benchmarking  comparision, average, large dataset Judgement • eg continual analysis of single changing  process over time Improvement
  8. 8. Research Judgement Improvement Goal New knowledge (not its  applicability) Comparison Reward / punishment Spur for change Process understanding Evaluating a change Hypothesis Fixed None Multiple and flexible Measures Many Very few Few Time period Long, past Long, past Short, current Sample Large Large Small Confounders Measure or control Describe and try to  measure Consider but rarely  measured Risks in  improvement  settings Ignores time based  variation Over‐engineers data  collection Ignores time based  variation Over‐reaction to natural  variation Incorrectly perceived as  ‘inferior statistics’  Measurement mindsets Based on L Solberg, G Mosser and S McDonald (1997) The Three Faces of Performance Measurement: Improvement, Accountability  and Research, Journal on Quality Improvement, 23 (3): 135 ‐ 147. 
  9. 9. What mind sets are at play here? Research Improvement Judgement
  10. 10. What do we collect now?
  11. 11. What does a great team meeting look like? Is that what we do?
  12. 12. SMART goals
  13. 13. Making better decisions about priorities Focusing your effort where it matters Prioritisation - The Pareto Principle
  14. 14. The Principle We don’t have time to improve everything A small number of issues account for the majority of the  challenge 20% of causes account for 80% of the problem We should focus on the ‘critical few’, not the ‘trivial  many’
  15. 15. What does it look like? Interruptions in surgeries Tally by GPs of the causes of interruptions while with a patient. Category Count Sign script ‐ contraception 72 Sign script ‐ minor illness nurse 18 Clinical query ‐ learner 18 Clinical query ‐ NP 24 Sign script ‐ urgent 78 Chaperone 198 Equipment search 60 Admin info 312 Clinical query ‐ GP 66 Panic button 6 Cancellation msg 588 Other 72 TOTALS 1512 0 100 200 300 400 500 600 700 Count
  16. 16. What does it look like? Interruptions in surgeries Tally by GPs of the causes of interruptions  while seeing patients. Category Count % of Total Cancellation msg 588 38.9 Admin info 312 20.6 Chaperone 198 13.1 Sign script ‐ urgent 78 5.2 Other 72 4.8 Sign script ‐ contraception 72 4.8 Clinical query ‐ GP 66 4.4 Equipment search 60 4 Clinical query ‐ NP 24 1.6 Clinical query ‐ learner 18 1.2 Sign script ‐ minor illness nurse 18 1.2 Panic button 6 0.4 TOTALS 1512 100 0 5 10 15 20 25 30 35 40 45 % of Total
  17. 17. What does it look like? 0 10 20 30 40 50 60 70 80 90 100 0 5 10 15 20 25 30 35 40 45 % of Total Cumulative %
  18. 18. What does it look like? 0 10 20 30 40 50 60 70 80 90 100 0 5 10 15 20 25 30 35 40 45 % of Total Cumulative % Three categories of interruption (17%) account for 73% of the problem
  19. 19. What to measure? Structure Process Outcome Avedis Donabedian ‘Outcomes remain the ultimate validators of the  effectiveness and quality of medical care’ but they ‘must  be used with discrimination’ The environment in  which care occurs What care is  delivered, and how The impact on  patients and the  population
  20. 20. What to measure? Structure Process Outcome o Outcomes are a worthy goal o All have pros & cons o Should measure a selection of all  three Veena Ralegh
  21. 21. What to measure? Structure Process Outcome “Intermediate outcomes” • a common solution • properties of both process & outcome • but be careful to acknowledge it’s  not ‘the ultimate outcome’
  22. 22. OUTPUTS HUMAN  FACTORS HUMAN FACTORS INTERNAL PROCESSES & PROCECEDURES INPUTSEXTERNAL FACTORS Process Measure(s) Outcome  Measure(s) Balancing  Measure(s) What to measure? Is it being done? Is it working? Unintended  consequences? Is it in place? Structure  Measure(s)
  23. 23. Metrics for different audiences Board Service managers Project managers Frontline staff Focus on outcome Focus on process Relevant process + outcome measures Relevant process + outcome measures Higher level outcome measures Highest level outcome measures
  24. 24. Driver Diagrams Benefits ... build complex strategy immediate visual Different scenarios ... 1. Help generate change ideas 2. Marshall a mass of change ideas 3. Survive failure / the unexpected avoid “silver bullet” thinking highlight overlooked ideas
  25. 25. Aim Defect Free Surgery Avoid  Mistakes Avoid Complications Avoid Delays Driver Intervention Conduct team brief Conduct team debrief Conduct time out Produce accurate lists Implement SSI bundle Implement VTE bundle Have correct kit to hand Ensure staff adequately trained O1 O2 O3 O1 Overall glitch count O2 Never events O3 Number of surgical site infections P1 % lists with Team Brief P2 % lists with Team Debrief P3 % compliance with SSI bundle P2 P1 P3 Driver Diagrams clinical example
  26. 26. AIM – an  improved  system Primary driver 1 Primary driver 2 How much?  By when? Secondary driver 1 Secondary driver 2 Secondary driver 3 Secondary driver 4 Secondary driver 5 CP1 CP2 CP3 CP4 CP5 CP6 CP7 How much?  By when? How much?  By when? AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE PROJECTS Driver Diagrams Planning & presenting change CauseEffect Drives
  27. 27. Driver Diagrams Weight loss example Pedometer Gym work out 3 days Squash weekends No pub weekdays Take packed lunch Low fat meals Buy only 1 sandwich Water bottle for work bag Fruit for dessert Put away the large glasses Put cycling days in diary Cycling kit out night before Get rid of Oyster cardBe more active during the day Do sport Drink less alcohol Substitute lower calorie foods Eat lessReduce calories in Increase calories out Take stairs 2 stone weight loss in 6/12
  28. 28. AIM Improve access Help marshal change ideas Waiting room info, list clinician interests/languages, web info, Rx access  (Feel Better Faster), signpost more (WIC/HV/minor inj/Secs/DNs/A&E),  Chronic disease training, care planning, review periods, get it right first  time, test results processing, teamworking/multiskilling, results line hours,  protocols for test results, widen skill mix, BP machine in watiting room,  update rpt Rx, pharmacist planning, streamline processes, streamline  recalls, education & reflection, up‐to‐date pt contact details, know what  appt is for, pt registration management, Triage, Care planning / pathways,  more TelC, emailC, clinical buddies/teams, test results, repeat Rx,  forwarding tasks + results, check + update usual GP, results actioned by  right person, advance appt booking, reserve list, ask pt who they want, rota  in advance, notekeeping w plan + pt info, Consult skills, comp skills, speed  reading/typing, forms + equipment, multi‐skilling, longer appts, No emerg  appts, Test results, Care planning, High risk processes, Referral chase‐up,  results continuity, streamline processes, streamline recalls, clear up alerts,   handling of normal results, self‐checkin, fast‐track queue 
  29. 29. AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE PROJECTS Improve access Doctors (capacity) Demand Dealing (efficiency) Appt system Supply of GP time Organisation of GP time Pt help‐seeking Deflecting demand Creating our own workload Planning care Appt system project GP rota change project Community education Waiting room TV PILS & CDs & DVDs  Feel better faster Student sick notes Reception signposting Test results Consulting skills Longer appts Guaranteed interpreters Help marshal change ideas Dealing w failed referrals Chronic disease pathways Review periods More TelC’s Email appts Continuity
  30. 30. AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE PROJECTS Improve access Doctors (capacity) Demand Dealing (efficiency) Appt system Supply of GP time Organisation of GP time Pt help‐seeking Deflecting demand Creating our own workload Planning care Appt system project GP rota change project Community education Waiting room TV PILS & CDs & DVDs  Feel better faster Student sick notes Reception signposting Test results Consulting skills Longer appts Guaranteed interpreters Survive failure / the unexpected Dealing w failed referrals Chronic disease pathways Review periods More TelC’s Email appts Continuity Telephone triage
  31. 31. Adapted from the Transform National Steering Group 2011, with input from the NHS  Institute for Innovation and Improvement
  32. 32. How much? By when?
  33. 33. Different audiences Board Service managers Project managers Frontline staff
  34. 34. What to measure? AIM – an  improved  system Primary driver 1 Primary driver 2 Secondary driver 1 Secondary driver 2 Secondary driver 3 Secondary driver 4 Secondary driver 5 CP1 CP2 CP3 CP4 CP5 CP6 CP7
  35. 35. What to measure? Add metrics to your driver diagram Structure Process Outcome Balance How much? By when? What is our baseline? How do we get it? 1. Identify measures for your aim, a primary driver and a secondary driver  using each of these four prompts 2. For each measure record your answer to these two questions 3. For each measure record your answer to these two questions 
  36. 36. How much & how often? There is no precise science to guide decisions about how  many metrics to use, or how often… How many different things are you monitoring consciously? How frequently? Straight motorwayReversing round a corner
  37. 37. The usual approach
  38. 38. Meeting rooms Real world Approve  Design Design Design Design Implement ! Courtesy of Patient Safety First Opinion
  39. 39. Meeting rooms Real world Courtesy of Patient Safety First Implement   Approve  Test &  refine Test &  refine Test &  refine Design Measurement
  40. 40. Change through small steps Change ... • with a clear purpose • you can learn from (without fear of failure) • which is less exhausting • with fewer unintended consequences • which builds engagement and optimism
  41. 41. What are we trying to accomplish? How will we know that change is an improvement? What change can we make that will result in improvement? The Model for Improvement Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994
  42. 42. Plan-Do-Study-Act disciplined framework ensures every part is done every  time
  43. 43. Plan-Do-Study-Act facilitates rapid prototyping and  rolling out of new ideas
  44. 44. Plan-Do-Study-Act
  45. 45. “We’re pressed for time, so we’ll be jumping to conclusions” We’re pressed for time, so we’ll  be jumping to conclusions
  46. 46. The Manager’s Dilemma In order to manage a system, we are required to make predictions about its future.
  47. 47. How do you look at your data ?
  48. 48. “If I stick my right foot in a bucket of boiling water and my left foot in a bucket of ice water, on the average, I’m pretty comfortable.” The Problem with Averages
  49. 49. The Problem Aggregated data presented in tabular formats or with summary statistics, will not help you measure the impact of improvement efforts. Aggregated data can only lead to judgment, not to improvement.
  50. 50. Enumerative Dynamic
  51. 51. Did things improve? What will happen next? Should we do something? Smoking Cessation :Percentage of smokers who have quit smoking after 4 week programme INTERVENTION
  52. 52. 1C-58 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% 10/3/2007 10/17/2007 10/31/2007 11/14/2007 11/28/2007 12/12/2007 12/26/2007 1/9/2008 1/23/2008 2/6/2008 2/20/2008 3/5/2008 3/19/2008 Change made here Did things improve? What will happen next? Should we do something? Smoking Cessation :Percentage of smokers who have quit smoking after 4 week programme
  53. 53. Protocol introduced Letter from Clinical Director Pharmacy included % surgical patients receiving Prophylactic Antibiotics 0 10 20 30 40 50 60 70 80 90 100 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 %reconciled Run Chart
  54. 54. Waiting time results 70 35 0 10 20 30 40 50 60 70 80 Avg Before Change Avg After Change WaitTime(min.)
  55. 55. Waiting time results 0 10 20 30 40 50 60 70 80 90 100 date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Change Made CycleTime(min.) 0 10 20 30 40 50 60 70 80 90 100 date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Change Made CycleTime(min.) Unit 1 Unit 3 0 10 20 30 40 50 60 70 80 90 100 date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Change Made CycleTime(min.) Unit 270 35 0 10 20 30 40 50 60 70 80 Avg Before Change Avg After Change WaitTime(min.)
  56. 56. If We Have 3 Numbers in Sequence: How Do You Report These? Downward Trend Upward Trend Some Recovery Setback Collapse Dramatic Recovery Each pattern has an equal 1:6 chance Lets Get Scientific! Data has no meaning without a Context
  57. 57. Run Charts Plot the dots 0 10 20 30 40 50 60 70 80 90 100 date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Change Made CycleTime(min.)
  58. 58. 0 20 40 60 80 100 120 Consecutive trips Min. My Trip To Work Mean Common Cause Special Cause
  59. 59. Statistical Process Control (SPC) Charts: No of Admissions 0 200 150 100 50 250 Performance Report – Number of Admissions Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 No Admissions          Median          Lower Limit (66.5)          Upper Limit (222.4) 65
  60. 60. It is normal to have some variation But some may be ‘special’ Control charts
  61. 61. 2 Ways To Improve A Process If controlled variation (Common Cause) • process is stable • variation is inherent to process • therefore, process must be changed i.e. Redesign  If uncontrolled variation (Special Cause) • process is unstable • variation is extrinsic to process • cause should be identified and “treated”
  62. 62. 7 steps to measurement https://www.youtube.com/watch?v=Za1o77jAnbw&list=PL_V1d0Y94nv4u2yCCDnApxa 9ykKmSG1oE
  63. 63. Insights into • Importance of measurement • Traditions of measurement • Knowing How We are Doing • Pareto principle • Structure ‐ process ‐ outcome measures • Driver diagrams • Model for improvement • Tracking variation • 7 steps to measurement
  64. 64. What do you need from your data?

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