Scottish Improvement Skills

1. Scottish Improvement Skills Leading change: From testing to implementation

2. System of Profound Knowledge Deming 2000

3. Leading change: from testing to implementation • By the end of this session you will be able to: • Describe typical stages in an improvement journey - testing, implementation and spread • Make decisions based on learning from PDSA cycles and data analysis • Demonstrate understanding of when to move from testing to implementation • Draft an implementation plan.

4. An improvement journey Spread Hold the gains A P S D Implement A P S D Sustain the change A P S D Test A P S D Plan A P S D Identify opportunity for change A P S D A P S D

5. An improvement journey Spread Hold the gains A P S D Implement A P S D Sustain the change A P S D Test A P S D Plan A P S D Identify opportunity for change A P S D A P S D

6. Examples of change: medicines reconciliation

7. Testing?Implementation?Spread? Failure is a useful, natural part of the improvement process.

8. Testing?Implementation?Spread? The change becomes part of the routine operation of the unit.

9. Testing?Implementation?Spread? Work out how to explain the benefits of a change beyond the unit.

10. Testing?Implementation?Spread? Use PDSA cycles.

11. Testing?Implementation?Spread? Learn what works in your system.

12. Testing?Implementation?Spread? Change is not permanent.

13. Testing?Implementation?Spread? Develop infrastructure (eg policies, job descriptions, SoPs) to maintain the improvement.

14. Test cycles: Act on your learning • Abandon the change • Modify the change • Increase the scope of the change • Test the change under different conditions • Stop collecting data • Implement the change

15. Three criteria for implementation • High degree of belief that a change will result in improvement • Small cost of failure • The organisation is ready to make the change.

16. From testing to implementation Adapted from: The Improvement Guide p146

17. Sequential building of knowledge A P S D Implementation cycles A P S D A P S D Learning and Improvement Wide scale tests A P S D Test new conditions A P S D Follow up tests A P S D Small scale test A P S D Very small scale test Develop a change

18. ICU: Reduce Length of Stay Aim Primary Driver Secondary Driver Change idea Assess sedation and agitation using the RASS tool (Richmond Agitation Sedation Scale) Validated sedation tool Assessment and management of sedation and agitation Develop and follow guidelines for daily sedation breaks Structured daily sedation breaks Improve multidisciplimary team communication Reduce average length of stay in Central General ICU by 20% by March 2015 Use Dexmedetomidine as alternative to benzodiazipines Appropriate sedation Use ear plugs to improve sleep Incidence of acute cognitive dysfunction Improved identification of delirium Medical staff and family jointly keep an ICU diary Assess for delirium using CAM-ICU (Confusion Assessment Method for ICU patients) Validated delirium tool Staff education Improved management of delirium Staff training sessions Include delirium as part of safety brief Staff information leaflets Investigate and correct underlying causes Care bundle initiated within 2 hours of diagnosis Engage with patient/family/carer Mobilise patients earlier and more frequently

19. PDSA Ramps A P S D A P S D A P S D Amend tool (wording) & test at 1 bed space Test with all staff Size poster to fit space A P S D A P S D A P S D Layout of poster more readable Revise wording – 1 nurse Test at 2 bed spaces A P S D A P S D A P S D Move poster so not obscured when doors opened Restructure content – 2 staff nurses Amend tool (colour) & test at 1 bed space A P S D A P S D A P S D Test at 1 bed space Display outside ward Test with 1 staff nurse A P S D A P S D A P S D Develop content Develop tool Develop poster RASS scoring tool Poster for families Education package

20. Building knowledge: your project • How could you increase your degree of belief? • What different conditions could you test your change under? • Which change ideas could you work on at the same time? • How could you minimise the cost of failure? • How could you better make your department/organisation ready for the change?

21. Components of Implementation • Standardisation eg policies, procedures • Documentation eg job descriptions • Training • Measurement • Resourcing eg equipment purchases

22. Aim: promote staff wellbeing Aim 1 Driver 2 Driver Change ideas Staff complete safety climate survey Promote the physical, mental and emotional wellbeing of staff. By March 2017: (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month. Environment Action planning from survey Lean visual management of cupboards, notice boards etc A workplace that is safe for staff Activity Use and location of hand gel dispensers Staff able to focus as required Schedule regular team huddles Leadership training for team leads People Staff engaged in health and wellbeing practices Offer Bereavement support programme for managers

23. Leading change: from testing to implementation: summary • An improvement journey • Criteria for implementation • PDSA ramps • Components of implementation