Improving Quality in Practice. Approaching Improvement in a Complex System

1. Improving Quality in Practice.Approaching Improvement in a Complex System SPICE and Service Improvement Methodology Jonathon Gray Director Healthcare Improvement Wales Centre for Health

2. PARIS IN THE THE SPRING

4. PARIS IN THE THE SPRING

6. How many legs does this elephant have?

7. The First Law Of Healthcare Improvement “Every system is perfectly designed to achieve exactly the results it gets” Therefore, Although Not All Change Is Improvement, All Improvement Is Change Source: Don Berwick, IHI (Boston)

8. Welsh Policy Context • 2003 Wales: A Better Country • Where are we going? • 2005 Designed for Life • What do we need? • 2005 Healthcare Standards for Wales • What do we do? • 2006 The Healthcare Quality Improvement Plan: Designed to Deliver • How will we get there?

9. Aims for Improvement “By 2015, Wales will have minimized avoidable deaths, pain, delays, helplessness, and waste.” Designed for Life • Safety • Effectiveness • Patient Experience • Timeliness • Efficiency

10. “The needs of the patient come first…..” • No needless deaths • No needless pain or suffering • No unwanted waiting • No helplessness • No waste • ……For anyone

11. What do we need to measure and why? IHI Model for Improvement

12. CAUTION! Gathering data can bring new and surprising knowledge to those who dare to seek it!

13. How Hazardous Is Health Care?

14. Hospital Death Rate(Standardized for Age, Sex, Race, Payer, Admission Source & Type) vs Charge per Admission(Standardized for Age and Diagnosis) -- AHRQ 1997 Data

15. Organisation with a Memory • 15,000 to 70,000 adverse events each year in the Wales NHS hospital sector (10 - 40% of admissions) • £100 million direct cost in additional hospital days alone • Clinical negligence cost - £85m (2004-05) • Half might be avoidable. Source: Organisation with a memory - CMO England)

16. Essential Elements for Large-Scale Change • Will • Ideas • Execution

17. We will explore new ways of working, recognising that there may now be better and different methods

19. The Knowledge Base for Continual Improvement Subject and Discipline Knowledge • Knowledge for • Improvement • Systems • Variation • Psychology • PDSA + Continual Improvement

20. 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? Act Plan Study Do The Project Method: The Model for Improvement (Nolan, et al.)

21. A P S D D S P A A P S D A P S D Repeated Use of the Cycle Changes That Result in Improvement DATA Hunches Theories Ideas

22. Leadership -Topic is a key strategic initiative -Goals and incentives aligned -Executive sponsor assigned -Day-to-day managers identified Measurement and Feedback Social System -Key messengers -Communities -Technical support -Transition issues Set-up -Target population -Adopter audiences -Successful sites -Key partners -Initial spread strategy Better Ideas -Develop the case -Describe the ideas Knowledge Management Communication Strategies (awareness & technical)

23. Acknowledgements:Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation

24. STRATEGY --Leadership --System Aims --Finance --Training --Environment MANAGING IMPROVEMENT TECHNIQUE --Statistics and Measurement --Systems Knowledge --Group Process --PDSA --Tools CULTURE --Teamwork --Cooperation --Operating Values --Beliefs and Myths Components of an Improvement System

25. Justin

26. Justin Micalizzi(by Dale Ann Micalizzi) • “On January 15th, 2001, Justin, a healthy 11-year old boy, was taken into surgery to incise and drain a swollen ankle. He was dead by 7:55 a.m. the next morning, leaving behind two grieving and bewildered parents who desperately wanted to know why their son had died. But medical care was to fail them twice- first their son died and then no one would explain to them why.”

27. Justin Micalizzi(by Dale Ann Micalizzi) • I know the chaos, the nursing shortages, overtime, the financial obligations, the insurance company guidelines and the arrogance that interferes with the quality of care. I have worked in healthcare and education for over 20 years. I also know, when it came time for my son’s surgery, you remove the chaos. You develop a team effort to review all information and establish a plan. You openly communicate between specialists, remove arrogance and intimidation and have a common goal to heal. It is your obligation to complete checklists, check and double check medications and dosages, assign a nursing team and treat every case as a possible emergency with the patient as your ONLY focus. Look at the child; listen to the parents and use common sense and professional judgment when making all decisions. Slow down! You are holding my child’s life in your hands. Justin WAS important and should have been important to his healthcare providers also. I trusted you.

28. Justin Micalizzi(by Dale Ann Micalizzi) • The hospital failed us, the nurses who were his advocates failed us, and the technicians who didn’t draw pre-op labs failed us. And, most importantly, the surgeon who gave the case to the resident and was NOT even in the OR at the time of surgery failed us. The health department failed us by accepting the medical personnel’s information as truthful. The hospital CEO failed us by not providing us with any information or support. Error upon accepted error killed my son and my faith in a medical system that was meant to comfort and heal. We will not let this happen to another family. The pain is unbearable.

29. Justin Micalizzi(by Dale Ann Micalizzi) “….. when it came time for my son’s surgery,you remove the chaos……”

30. The Simple, Wrong Answer Blame Somebody

31. The First Law of Improvement “Every System Is Perfectly Designed to Achieve Exactly the Results It Gets” (Therefore, Although Not All Change Is Improvement, All Improvement Is Change)