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West of England: Maternal & Neonatal learning system launch event

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This work is part of the NHS Improvement's National Maternal and Neonatal Health Safety Collaborative. The Learning System aims to create a safe space for local learning and sharing

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West of England: Maternal & Neonatal learning system launch event

  1. 1. 3 July 2018 Launch of the Local Learning System (LLS)
  2. 2. As the only bodies that connect NHS and academic organisations, local authorities, the third sector and industry, we are catalysts that create the right conditions to facilitate change across whole health and social care economies, with a clear focus on improving outcomes for patients.
  3. 3. Region wide: Neonatal Network Maternity Network Local Coordinating Group
  4. 4. West of England AHSN South West AHSN
  5. 5. LMS LMS LMS LMS LMS LMS LMS NHS England South region Local Maternity Systems aligned to STPs Southampton, Hampshire, Isle of Wight and. Portsmouth LMS
  6. 6. West of England Learning System Devon and Cornwall Learning System Wessex Learning System (Dorset and SHIP LMSs)
  7. 7. Wave 1(17/18) • University Hospitals Bristol NHS FT (including Weston-Super-Mare maternity services) Wave 2 (18/19) • Great Western Hospitals NHS FT • Taunton and Somerset NHS FT Wave 3 (19/20) • Gloucestershire Hospitals NHS FT (including Gloucester, Stroud and Cheltenham maternity services) • North Bristol NHS Trust • Royal United Hospitals Bath NHS FT • Yeovil District Hospital NHS FT
  8. 8. Tony Kelly Introduction to the Maternal and Neonatal Health Safety Collaborative
  9. 9. Tony Kelly National Clinical Lead, MNHSC An introduction, of sorts…
  10. 10. @MatNeoQI Where do we start? 12
  11. 11. @MatNeoQI Where do we start? 13
  12. 12. @MatNeoQI IHI Model for improvement 14 What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement?
  13. 13. @MatNeoQI Continuous breakthrough improvement…. 15 ..results from a series of improvement cycles Hunches, theories & ideas Changes that result in improvement
  14. 14. @MatNeoQI Where do we start? 16
  15. 15. @MatNeoQI What is the patient pathway? 17 Woman admitted in threatened pre- term labour Is risk of delivery high? No/Unclear Yes (FFN>200) Okay to deliver in unit? Yes No Arrange in-utero transfer Less than 30 weeks? Yes No Administer MgSO4 Observe
  16. 16. Primary Drivers Peri-partum Optimisation: Support the effective optimisation of preterm infants around the time of birth Post-partum Optimisation: Support the effective optimisation of preterm infants immediately after the time of birth Antenatal Optimisation: Support the effective optimisation of preterm infants prior to the time of birth Aim To improve the optimisation and stabilisation of the very preterm infant Evidenced by (i) a reduction in the proportion of babies admitted to neonatal units with hypothermia (temperature <36.5oC) (ii) Proportion of babies delivered in appropriate care setting for gestation Ensure all women in threatened pre- term labour (less than 34 weeks gestation) receive a full course of antenatal corticosteroids Ensure all women in threatened preterm labour are informed of the increased benefits of breast milk and breastfeeding for preterm infants Ensure all women in threatened pre- term labour (less than 30 weeks gestation) receive an infusion of Magnesium Sulphate Ensure that appropriate information and equipment is available prior to delivery to support timely expressing within four hours of delivery Develop a consistent approach for the need for in-utero transfer
  17. 17. Primary Drivers Peri-partum Optimisation: Support the effective optimisation of preterm infants around the time of birth Post-partum Optimisation: Support the effective optimisation of preterm infants immediately after the time of birth Antenatal Optimisation: Support the effective optimisation of preterm infants prior to the time of birth Aim To improve the optimisation and stabilisation of the very preterm infant Evidenced by (i) a reduction in the proportion of babies admitted to neonatal units with hypothermia (temperature <36.5oC) (ii) Proportion of babies delivered in appropriate care setting for gestation
  18. 18. Primary Drivers Secondary Drivers Creating the conditions for a culture of safety and continuous improvement Improve the experience of mothers, families and staff Improve the optimisation and stabilisation of the very preterm infant Develop safe and highly reliable systems, processes and pathways of care Aim To improve outcomes and reduce unwarranted variation by providing a safe, high quality healthcare experience for all women, babies and families across maternity care settings in England. Reduce the rate of stillbirths, neonatal death and brain injuries occurring during or soon after birth by 20% by 2020 Learn from excellence and harm Improving the quality and safety of care through Clinical Excellence
  19. 19. Primary Drivers Improve the detection and management of diabetes in pregnancy Improve the early recognition and management of deterioration during labour & early post partum period Improve the detection and management of neonatal hypoglycaemia Improve the optimisation and stabilisation of the very preterm infant Aim To improve outcomes and reduce unwarranted variation by providing a safe, high quality healthcare experience for all women, babies and families across maternity care settings in England. Reduce the rate of stillbirths, neonatal death and brain injuries occurring during or soon after birth by 20% by 2020 Improve the proportion of smoke free pregnancies
  20. 20. Primary Drivers Secondary Drivers Creating the conditions for a culture of safety and continuous improvement Improve the experience of mothers, families and staff Improve the detection and management of diabetes in pregnancy Improve the early recognition and management of deterioration during labour & early post partum period Improve the detection and management of neonatal hypoglycaemia Improve the optimisation and stabilisation of the very preterm infant Develop safe and highly reliable systems, processes and pathways of care Aim To improve outcomes and reduce unwarranted variation by providing a safe, high quality healthcare experience for all women, babies and families across maternity care settings in England. Reduce the rate of stillbirths, neonatal death and brain injuries occurring during or soon after birth by 20% by 2020 Improve the proportion of smoke free pregnancies Learn from excellence and harm Improving the quality and safety of care through Clinical Excellence
  21. 21. 23 Jan Feb Mar April May June July Aug Sept Oct Nov Dec 24% 24% 23% 20% 24% 28% 28% 24% 24% 31% 20% 24% How are data often used? @MatNeoQI
  22. 22. 24 How can you use data to support improvement? @MatNeoQI
  23. 23. @MatNeoQI To improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity care settings in England” What is the aim of the collaborative? 25
  24. 24. @MatNeoQI By 2020 each Trust, local maternity system and network should have: • significant capability (& capacity) for improvement • detailed knowledge of local cultural issues • developed a locally sensitive improvement plan • made significant improvement to local service quality and safety • data to share with their board, staff and commissioners that reflect these improvements …to create the conditions for a safety culture and a national maternal and neonatal learning system What is the ambition of the collaborative? 26
  25. 25. @MatNeoQI Yes • All maternity services in England • All care settings • All components of the pathway (conception to puerperium) through a safety lens No • The entire LMS agenda! • Elements of care outside of the influence of clinical teams • (limited influence on improvement in maternal mortality) What is within the scope of the collaborative? 27
  26. 26. @MatNeoQI How is the collaborative structured? National Learning Set (Trust Improvement) Trust Trust Trust Trust Trust Trust Trust 28
  27. 27. @MatNeoQI What additional support do organisations in the national learning set receive? 29 Annual national learning event Access to LIFE improvement platform Measurement for improvement support Tailored resources and networks Local Learning System Improvement & capability development (per wave) Site Support (per wave) Wave learning sessions (per wave)
  28. 28. @MatNeoQI How is the collaborative structured? National Learning Set (Trust Improvement) Trust Trust Trust Trust Trust Trust Trust Local Learning Systems (Trust & System Improvement) Trust Trust Trust Trust LMS LMS 30
  29. 29. @MatNeoQI Why is context so important? 31
  30. 30. How has the national context shifted? 32 • Kirkup report @MatNeoQI
  31. 31. How has the national context shifted? 33 • Kirkup report • Better Births @MatNeoQI
  32. 32. How has the national context shifted? 34 • Kirkup report • Better Births • Each Baby Counts @MatNeoQI
  33. 33. How has the national context shifted? 35 • Kirkup report • Better Births • Each Baby Counts • MBRRACE @MatNeoQI
  34. 34. How has the national context shifted? 36 • Kirkup report • Better Births • Each Baby Counts • MBRRACE • Maternity Transformation Programme @MatNeoQI
  35. 35. @MatNeoQI What about the culture? 37
  36. 36. @MatNeoQI What about the culture? 38
  37. 37. @MatNeoQI What about the culture? 39
  38. 38. Primary Drivers Work with staff to improve the work environment to support staff to deliver safer care Work effectively with local network and commissioning organisations to develop effective local maternity systems Work with mothers and families to improve their experience of care Aim Improve the experience of women, families and staff @MatNeoQI 40
  39. 39. Capability Common ambition Counting Collaboration Context Culture (Person) Centred 41 @MatNeoQI
  40. 40. @MatNeoQI To improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity care settings in England” What is the aim of the collaborative? 42
  41. 41. 43 @MatNeoQI A word of warning…..
  42. 42. @MatNeoQI @MatneoQI @tonykellyuk #MatNeoQI www.improvement.nhs.uk Thank you 44
  43. 43. Ann Remmers MatNeoQI: The Journey So Far
  44. 44. • Fantastic commitment of staff working exceptionally hard to do the right thing • Wide variation in QI capability - iterative journey of improvement • Teams that have had the greatest success have clear aims, assigned roles and effective methods of communication • Recognising the impact we can make as a collaborative - spread and adoption across the NHS
  45. 45. • Enthusiasm counts for a lot – if people are keen to be involved, that’s great, so go with it • It’s more about the person than the job title –staff at any level can make a fantastic contribution • Make sure your team have psychological safety and feel comfortable to speaking up and suggest improvements– it’s the only way you will learn • Make sure your team is diverse with different professional groups and seniority represented – don’t forget to include a neonatologist • Meet regularly – short focused stand up meetings around the learning board on a weekly basis work really well • Think about how best to communicate – maybe set up a what’s app or facebook page whatever works best for you • Put all your meetings in the diary from the outset so you can protect that time • Share out tasks amongst the whole team to spread the workload • Use the 3 day learning events to network, share what you are doing and plan your work, bond as a team • Engage all staff especially those closest to the process • This is really hard work – but so worth it!!
  46. 46. • Make sure you meet as a team with your executive sponsor to update on progress and any issues/ challenges • Make sure you get early engagement and keep it going through out the collaborative
  47. 47. • Collaborate with other sites working on the same topics – share and spread the learning • Keep it realistic and achievable within the timescale available • Use data to inform your choice of projects and ask the wider team what they think • Focus on areas where there is momentum within your organisation if possible • Designate a lead for each element of the project who can drive forward • Consider holding a launch day for the collaborative within your trust to raise • awareness and gain support and help • Communicate what you are doing using newsletters/team briefs etc • Celebrate every victory – it’s a long journey and not a quick fix! • Give people time to do the work! • Involve the mothers and families using services in your projects
  48. 48. • Engage local QI support from the trust • Gain support from your IT, analysist and communications team to help with projects • Report internally and regularly to your directorate and board • Use Life QI and share your work with others – also feel free to steal shamelessly from others • Add dates to your diary when the monthly reports are due and allocate the task to a member of the team
  49. 49. • Shared learning across networks and Local Maternity Systems • Themes aligned to the Five Clinical Drivers • Open to all working in maternity and neonatal services • Involve women and families, Maternity Voice Partnerships • Quality Improvement • Four events per year
  50. 50. We are…. We’re great at…. We want to work with… We want to work on… We want to meet every… If the Learning System could do one thing… ….months We want to learn about… o quality improvement o measurement o human factors o appreciative inquiry o …anything else? o Smoking cessation o Diabetes in pregnancy o Recognition and management of deterioration o Neonatal hypoglycaemia o Optimisation and stabilisation of very preterm infants #PSCollaborative #MatNeoQI Many thanks to London for sharing this resource
  51. 51. Life QI is a web software platform built to support and manage quality improvement work in health and social care. It makes it easy for teams to run QI projects and organisations to report on QI activity.
  52. 52. Life QI is a web software platform built to support and manage quality improvement work in health and social care. It makes it easy for teams to run QI projects and organisations to report on QI activity.
  53. 53. • www.weahsn.net/matneoqi
  54. 54. Tricia Woodhead Lightning QI
  55. 55. “The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of care, top to bottom and end to end.” A Promise to Learn, A Commitment to Act Don Berwick, August 2013
  56. 56. @AmandaConsSci
  57. 57. DesignThinkingPlaybook
  58. 58. HannahWarren
  59. 59. #QIin4objects https://scotpublichealth.com/2017/10/15/quality-improvement-explained-in-four-everyday-objects/ http://weclipart.com/gimg/8A7FEEF7C4B61AC1/yiogR9j6T.jpeg Process Outcome Balancing
  60. 60. http://www.nhsemployers.org/~/media/Employers/Documents/Campaigns/Do%20OD/Visual %20dialogue%20tool.jpg
  61. 61. 1. Defer judgement
  62. 62. 2. Encourage wild ideas
  63. 63. 3. Build on the ideas of others
  64. 64. 4. Stay focused on the topic
  65. 65. 5. One conversation at a time
  66. 66. 6. Be visual
  67. 67. 7. Go for quantity
  68. 68. Systems Design for Safer Care • Thinking outside the immediate system • Understanding the variation and the psychologies • Building a plan for what to measure • Forming a team confident to brain storm Organising our ideas to reduce the holes in the Swiss cheese Designing safer care using human factors concepts
  69. 69. 2 Probability of on-time successful completion at each step Steps 90.00% 99.00% 99.90% 99.99% 99.999% 1 90.00% 99.00% 99.90% 99.99% 99.999% 2 81.00% 98.01% 99.80% 99.98% 99.998% 4 65.61% 96.06% 99.60% 99.96% 99.996% 8 43.05% 92.27% 99.20% 99.92% 99.992% 16 18.53% 85.15% 98.41% 99.84% 99.984% 32 3.43% 72.50% 96.85% 99.68% 99.968% 64 0.12% 52.56% 93.80% 99.36% 99.936% 128 0.00% 27.63% 87.98% 98.73% 99.872% How does the complexity of your process affect reliability? Aim: over 90% compliance with optimised management of deterioration (4 step process) RELIABILITY IS ABOUT THE MATHS Obs completed on time (52-68% because 32% incomplete 42% delayed) NEWS calculated correctly (20-50% correct) Escalation appropriate (64%) Response on time right person (20%) = 0.5x0.5x0.64x0.2= 2%
  70. 70. 2 Probability of on-time successful completion at each step Steps 90.00% 99.00% 99.90% 99.99% 99.999% 1 90.00% 99.00% 99.90% 99.99% 99.999% 2 81.00% 98.01% 99.80% 99.98% 99.998% 4 65.61% 96.06% 99.60% 99.96% 99.996% 8 43.05% 92.27% 99.20% 99.92% 99.992% 16 18.53% 85.15% 98.41% 99.84% 99.984% 32 3.43% 72.50% 96.85% 99.68% 99.968% 64 0.12% 52.56% 93.80% 99.36% 99.936% 128 0.00% 27.63% 87.98% 98.73% 99.872% How does the complexity of your process affect reliability? HOW RELIABLE ARE WE NOW 61% Aim: “90% compliance with optimised management of deterioration (4 step process) Reliability is about the mathematics Obs completed on time (85%) NEWS calculated correctly (100%) Escalation appropriate (85%) Response on time right person (85%))
  71. 71. 2 Probability of on-time successful completion at each step Steps 90.00% 99.00% 99.90% 99.99% 99.999% 1 90.00% 99.00% 99.90% 99.99% 99.999% 2 81.00% 98.01% 99.80% 99.98% 99.998% 4 65.61% 96.06% 99.60% 99.96% 99.996% 8 43.05% 92.27% 99.20% 99.92% 99.992% 16 18.53% 85.15% 98.41% 99.84% 99.984% 32 3.43% 72.50% 96.85% 99.68% 99.968% 64 0.12% 52.56% 93.80% 99.36% 99.936% 128 0.00% 27.63% 87.98% 98.73% 99.872% How does the complexity of your process affect reliability? Aim: over 90% compliance with optimised management of deterioration (4 step process) RELIABILITY IS ABOUT THE MATHS All eligible patient identified Drugs available within five minutes Drugs administered within one hour = 0.5x0.5x0.64x0.2= 2%
  72. 72. Human Factors always need attention Organisational accident model (Adapted from Reason, 1997)
  73. 73. SAFE DESIGN –Systems Engineering Initiative for Patient Safety (SEIPS) model creates a check list for what could be changed TECHNOLOGY AND TOOLS ORGANISATION PEOPLE TASK ENVIRONMENT Carayon et al Quality and Safety Healthcare ; 2006 15 i50-8 BMJ Publishing Group PATIENT, STAFF AND ORGANISATION OUTCOME CHANGE
  74. 74. Nathalie Delaney Learning Systems
  75. 75. • A forum for local improvement to thrive • An opportunity for all network partners to work collaboratively • Effective collaboration between local partners • Opportunities for system level improvement • An opportunity for increasing local improvement capability • A sustainable solution for maternal and neonatal improvement
  76. 76. • Base • Rice • Meat or vegetables • Spice Thank you to Chris Collison for the inspiration
  77. 77. How many people at each event? Face-to-face, virtual? Where works best for the geographical area?
  78. 78. Chopped onion, celery, peppers Cut very small Slowly sautéed
  79. 79. Our charter is the summary of the key ingredients that will make our Learning System successful. • Purpose • Membership • Behaviours • Tools • Measures
  80. 80. We are…. We’re great at…. We want to work with… We want to work on… We want to meet every… If the Learning System could do one thing… ….months We want to learn about… o quality improvement o measurement o human factors o appreciative inquiry o …anything else? o Smoking cessation o Diabetes in pregnancy o Recognition and management of deterioration o Neonatal hypoglycaemia o Optimisation and stabilisation of very preterm infants #PSCollaborative #MatNeoQI Many thanks to London for sharing this resource
  81. 81. Add in the rice and stock. You need the right rice – short-grained rice that will not disintegrate during the cooking (i.e. not risotto rice).
  82. 82. Quality Improvement • IHI Model for Improvement • Measuring for Improvement • LifeQI Safety Culture • Safety Culture toolkit • SCORE survey • Human Factors and Ergonomics
  83. 83. Paellas are traditionally one of three types: • Paella Valenciana (chicken, pork or rabbit) • Paella Marisoc (seafood) • Paella Mixta (a mixture) You can also make vegetable paella.
  84. 84. Improve the proportion of smoke free pregnancies Improve the optimisation and stabilisation of the very preterm infant Improve the detection and management of diabetes in pregnancy Improve the detection and management of neonatal hypoglycaemia Improve the early recognition and management of deterioration during labour and early post partum period We are…. Mark where you think your organisation is on the improvement journey for the Big 5 topics Don’t know Solved it!Getting started
  85. 85. • Paella’s distinctive yellow colour comes from saffron. • Adding a squeeze of fresh lemon at the end can make the flavours pop.
  86. 86. • We don’t want to be bland or business as usual! • Expert speakers • Individual experiences • Fun and interactive
  87. 87. Let us know your TREEs... Transferred knowledge Reused resources Embedded changes Experiences shared
  88. 88. • Periodically checking the temperature and stirring to ensure contents are receiving the right amount of heat and not sticking to the pan
  89. 89. • Thank you for filling in our baseline survey • Please fill in our evaluation survey for today • We will check in with you regularly • Please feedback any ideas you have for how we can improve • If you feel stuck, cold or too hot let us know!
  90. 90. • How often should we meet? • What ways of communicating works best for you?
  91. 91. • Do we have the right members of our learning system? • Who are we missing and need to invite? • Do you want specific time in LMS groups planned in as part of the event? • How do you want to learn and share resources with each other? • How can we help newcomers feel like they belong? • How can we continue the learning and sharing when it’s really busy?
  92. 92. • Our charter • Pre-mortem
  93. 93. • Make a list of everything you can do to: make the Local Learning System fail • Take 2 minutes to create your individual list • After that share your ideas on your table and capture them in flipchart
  94. 94. • Have you ever experienced any of the items on your list? • Please circle these items • Have a discussion per circled item and share your experiences
  95. 95. • How can we solve these? • What can I / we (learning system) / Patient Safety collaborative / others contribute to stop this from happening?
  96. 96. We are…. We’re great at…. We want to work with… We want to work on… We want to meet every… If the Learning System could do one thing… ….months We want to learn about… o quality improvement o measurement o human factors o appreciative inquiry o …anything else? o Smoking cessation o Diabetes in pregnancy o Recognition and management of deterioration o Neonatal hypoglycaemia o Optimisation and stabilisation of very preterm infants #PSCollaborative #MatNeoQI Many thanks to London for sharing this resource
  97. 97. Ann Remmers Summary and Next Steps
  98. 98. • Please complete evaluation form • Check out www.weahsn.net/matneoqi • See you on the 10 October 2018 at the Holiday Inn Filton Bristol.

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