Improving the quality and safety of your service Zoe Lord & Carol Marley, Improvement Managers, Patient Safety Team NHS Improving Quality Presentation from the Annual Residential Higher Trainee Intellectual Disability Conference 6 & 7 November 2014 Thistle Hotel, Manchester

1. Improving the Quality and Safety of
your Service
Carol Marley - Improvement Manager
Improving health outcomes across England by providing improvement and change expertise

2. Take a few minutes to think
about something you would
like to change have a chat
to the person next to you
about your idea

3. “Here is Edward Bear coming downstairs
now, bump, bump, bump, on the back of
his head, behind Christopher Robin. It is,
as far as he knows, the only way of
coming downstairs, but sometimes he
feels that there really is another way…
if only he could stop bumping for
a moment and think of it!”
A. A. Milne

4. • Improvement work is not difficult
• It’s not necessary to start from scratch
• It’s pointless to just tell people to work harder;
it’s better to try and work differently
• If you don’t do things differently, things won’t
change and are unlikely to improve
Time out

6. “Every system is perfectly designed to get
the results it achieves”
Paul Batalden
Dartmouth Medical School, New Hampshire, USA.

7. The NHS Change Model
8 components

8. Aims
Measurements
Change ideas
The Improvement Guide
Langley et al (1996)
Model for Improvement
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 the improvements that we seek
?
Act Plan
Study Do
Testing ideas before
implementing changes

9. The ‘Plan, Do, Study, Act’ cycle

10. What are you trying to accomplish?
First define your aim…

11. We all know what we are doing…
• Can you picture…

13. Why does defining your aim matter?
• If you don’t know where you are going, you
are likely to end up somewhere else…
• How do we know what to measure if we don’t
know what we are trying to achieve?
• Focus on the problem and the gap – what do
you need to tackle and what will it change?
• It’s not about the solution!

14. Getting the right people
involved and supporting
the process of change

15. How you feel about change?

16. Attitudes to change differ…
Proportionate
enthusiasm
Healthy
scepticism
Annoying
evangelism
Irrational
obstructionism
Moderate
interest

17. How do you feel if your not told
about changes?
How do you feel if you’re the last
to know?

18. Have you got the right people involved?
• Psychiatrists, nurses, managers, care staff,
pharmacists, patients, carers, families,
commissioners, trust service improvement /
project management office, communications
team, chief executive, schools …

19. Attitudes to change differ…
Proportionate
enthusiasm
Healthy
scepticism
Annoying
evangelism
Irrational
obstructionism
Moderate
interest

20. Attitudes to change
Proportionate
enthusiasm
Healthy
scepticism
Annoying
evangelism
Irrational
obstructionism
Moderate
interest
Calming down
Keeping in real world
Perspective
Focussing ?
Support
Direction
Feedback
Motivating
Exploring
Evidence of benefit
“Unpacking”
Debate (argument)
Selling

21. What are you going to tell them
and how??

22. ADD Grief loss model

23. We all respond differently
• Analyst
• Amiable
• Social (Expressive)
• Driver

24. Analyst Amiable Expressive Driver
Analytical Patient Verbal Action-orientated
Controlled Loyal Motivating Decisive
Orderly Sympathetic Enthusiastic Problem solver
Precise Team person Gregarious Direct
Disciplined Relaxed Convincing Assertive
Deliberate Mature Impulsive Demanding
Cautious Supportive Generous Risk-taker
Diplomatic Stable Influential Forceful
Accurate Considerate Charming Competitive
Conscientious Empathetic Confident Independent
Fact finder Persevering Inspiring Determined
Systematic Trusting Dramatic Results-orientated
Logical Congenial Optimistic
Conventional Animated

25. The Analyst: Technical Specialist
May be perceived
positively as
May be perceived
negatively as
How to work better
with analysts
• accurate • critical • tell how first
• conscientious • picky • list pros & cons
• serious • moralistic • be accurate & logical
• persistent • stuffy • provide evidence
• organised • stubborn • provide deadlines
• deliberate • indecisive • give them time
• cautious • don’t rush or surprise

26. The Analyst
• Interested in, and places an high value on, facts, figures, data
and reason
• Others may describe them as analytical, systematic or
methodical
• They tend to follow an orderly approach when tackling tasks
• Well organised and thorough
• Sometimes seen as too cautious, overly structured and does
things ‘by the book’
• They analyse, consider and project
• They view time in a linear (sequential) fashion

27. Communicating with an Analyst
• They want facts, figures and data in the
message
• It should be presented in an orderly fashion,
with supporting documentation
• Give them time to examine reports etc
Written communications will be quite formal and precise,
listing key points.
They may use and outline style, with sub-headings and
numbered sections.
Tables and appendices, with facts and figures will also be
included.

28. The Amiable: Relationship Specialist
May be perceived
positively as
May be perceived
negatively as
How to work better
with amiables
• patient • hesitant • tell why & who first
• respectful • ‘wishy-washy’ • ask instead of telling
• willing • pliant • draw out their opinions
• agreeable • conforming • chat about their life
• dependable • dependent • define expectations
• concerned • unsure • strive for harmony
• relaxed • laid back
• organised
• mature
• empathetic

29. The Amiable
• Interested in, & places a high value on, relationships, feelings,
interactions and affiliation with others
• Often described as warm and sensitive to feelings of others,
and a loyal & supportive friend
• May be viewed as too emotional/ sentimental and too easily
swayed by others
• Will often make reference to past events and their
relationships over a period of time

30. Communicating with an Amiable
• Make sure the human dimensions of the situation are
included
• Include how others may feel about the matter
• Let them know who else will be involved
• Include past experiences in a similar situation
Written communications will be quite informal, chatty and
friendly.
They may inject names and make reference to others and to past
events

31. The Expressive: Social Specialist
May be perceived
positively as
May be perceived
negatively as
How to work better with
expressives
• verbal • a talker • tell who first
• inspiring • overly dramatic • be enthusiastic
• ambitious • impulsive • allow for fun
• enthusiastic • undisciplined • support their creativity &
intuition
• energetic • excitable • talk about people & goals
• confident • egotistical • value feelings & opinions
• friendly • flaky • keep fast paced
• influential • manipulating • be flexible

32. The Expressive
• Interested in taking people with them, enthusing them with
optimism and energy
• Tend to be open with people and willing to make a personal
investment
• Generally very good with people
• Can frighten people by being over-dominant
• May feel personally let down by people or left out
• They tend to be poor with detail
• Their hunches can go wrong

33. Communicating with an Expressive
• They will be looking for the new and the
exciting aspects of the message
• Include some kind of innovation to hook the
expressive
Written communications can tend to be rather vague and
abstract.
They are inclined to be idea orientated and are often quite
lengthy in making a point.

34. The Driver: Command Specialist
May be perceived
positively as
May be perceived
negatively as
How to work better
with drivers
• decisive • pushy • tell what & when first
• independent • one man show • keep fast paced
• practical • tough • don’t waste time
• determined • demanding • be business like
• efficient • dominating • give some freedom
• assertive • an agitator • talk results
• risk-taker • cuts corners • find shortcuts
• direct • insensitive
• a problem solver

35. The Driver
• Places great emphasis on action and results
• Often viewed as decisive, direct and pragmatic
• They view time as here and now, like to get things done and
hate spinning things out
• They translate ideas into action, and are dynamic &
resourceful
• Sometimes accused of only seeing the short term, and
neglecting long-range implications
• Can be seen as too impulsive, simplistic, and acting before
they think

36. Communicating with a Driver
• They will want to know ‘what are we going to
do’?
• ‘How soon we are going to do it’ is also very
important to them
Written communications will be brief, sketchy and crisp.
They may resent having to take the time to write and will often
scribble a reply on the senders original message and return it to
them.

37. Measurement for Improvement
“All improvement will require change,
but not all change will result in improvement”

38. Aims
Measurements
Change ideas
The Improvement Guide
Langley et al (1996)
Model for Improvement
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 the improvements that we seek
?
Act Plan
Study Do
Testing ideas before
implementing changes

39. “It feels like…” or “I think …” just
isn’t enough

40. If you don’t measure, you wont know…
• If the changes we make have actually made a difference
• If it is an improvement
• How much difference the change has made
• If the improvement has stayed in place?
• Measurement can show:
– How well the current testing is performing
– Whether you have reached your aim
– How much variation there is in the data/process
– Small test of change
– Whether the changes have resulted in improvement
– Whether a change has been sustained

41. Top tips when starting to measure:
• Seek usefulness not perfection
• Measure the minimum.
• Remember the goal is improvement and not a new
measurement system.
• Aim to make measurement part of the daily routine.
• Don’t let measure issues delay the start of your PDSA
cycles.

42. Why Baseline?
• To understand current position
• Development of a hypothesis
• Enables teams to define success
• For evaluation purposes
• Before and After comparisons
• Assessment
• ??How much data??

43. Where can we get data from?

44. Project Metrics
• Don’t forget to baseline
• Measure times between patient journey steps
A B
• Measure the demand on the service
• Measure your capacity
•
• Number on caseload

45. Got the data… what next?
Understanding the information
Root Cause Analysis
Problem Solving

46. Tools to help people through the change process
•Communicate communicate communicate
•Be inclusive
•What’s in it for me
•Deal with conflict as it occurs
•Don’t tolerate bad behaviour
•Be honest
•Manage expectations
•Be aspirational/accountable/disciplined
•Don’t impose solutions baste on emotion/opinion
•Be part of the action plan

47. Leadership
Culture