Scottish Improvement Skills Workshop 2

1. Scottish Improvement Skills Workshop 2

2. Housekeeping

3. Workshop 1 • By the end of the workshop, you will have planned a first test of change to carry out in the workplace, taking into account the work context and priorities for improvement, and the needs of stakeholders.

4. Project work • By the time your return for Workshop 2, you will have: • reviewed the Three Questions with your team • collected data to help you identify your priority for change • collected baseline data • carried out several tests of change • collected qualitative and quantitative data

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6. Workshop 2 • By the end of the workshop, you will have created run charts with your own project data, and practised talking about your data with your team or other stakeholders.

7. Workshop 2 Content • Interpretation of run charts • Creating run charts on MSExcel • An improvement journey: from testing to implementation • Talking about data in run charts

8. Improvement principles • By the end of this session you will be able to: • apply Deming’s System of Profound Knowledge to help you understand the complexity in your improvement project.

9. System of Profound Knowledge Deming 2000

10. 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

11. System of Profound Knowledge Deming 2000

12. System of Profound Knowledge • Which of the 4 components are you finding most challenging in your project right now? Is this reflected in what you’ve included, or in there being gaps? • What would you advise the project team to work on?

13. System of Profound Knowledge Deming 2000

14. Analysing data: interpretation of run charts • By the end of this session you will be able to: • Explain the importance of using annotation to help interpret run charts • Discuss how the type of median used affects interpretation of signals from run charts and impacts on decision making • Explain use of phasing, stratification, and what to do with extreme values on run charts.

15. Analysing data: Interpretation of run charts • Annotation • Median • Phasing • Extreme values • Stratification

16. Aim: promote staff wellbeing Aim 1 Driver 2 Driver Change ideas Offer Bereavement support programme for managers Promote the physical, mental and emotional wellbeing of staff. Within 12 months (1) reduce staff absences from 5.2% to 4.2% (2) reduce staff related incidents from 140 to 100 per month. A workplace that is safe for staff Flyer on staff health and wellbeing programmes Staff education Hold staff health fairs Smoking cessation campaign Staff engaged in health and wellbeing practices Set up walking groups Healthy lifestyle programmes for staff Improve staff diet at work Offer lunchtime yoga Enable cycling to/from work

17. AnnotationHours lost through sickness absence Median 5.2 Fit Note introduced Goal

18. Median (1)Women walking 10,000 steps Baseline medianExtended median Challenge announced Pedometers issued

19. Median (2)Women walking 10,000 steps Signal detected here Challenge announced Pedometers issued

20. Median (1)Women walking 10,000 steps Baseline medianExtended median Signal detected here Challenge announced Pedometers issued

21. Creating a baseline median • Use historical data if available • Collect new baseline data before introducing a change, if this makes sense in your context • If no baseline data is available, create a baseline median using the first 10 data points.

22. PhasingWomen walking 10,000 steps Pedometers issued Challenge announced

23. Interpretation of run charts • Each run chart can be improved to make the data easier to interpret. Possible improvements may relate to: Type of median line used Measure used • For each chart, decide what improvements would be most useful, and why. Annotation Design

24. Extreme values • Frequent events • Rare events • More than half the data falls on the median line • More than half the data is at ‘extreme’ values eg 0 or 100 on percentage scale

25. Extreme values (1)Compliance with hand hygiene

26. Extreme values (2a): Number of needlestick incidents per month

27. Extreme values (2b): Number of patients seen between needlestick incidents

28. Stratification (1):Inpatient requests for MRI

29. Stratification (1): Inpatient requests for MRI

30. Stratification (1): Inpatient requests for MRI

31. Stratification (2) Staff walking 10,000 steps (men and women) Median 35.25 Challenge announced Pedometers issued

32. Stratification (2) Staff walking 10,000 steps (women) Median 29 Pedometers issued Challenge announced

33. Stratification (2) Staff walking 10,000 steps (men) Median 41 Pedometers issued Challenge announced

34. Interpretation of run charts • Each run chart can be improved to make the data easier to interpret. Possible improvements may relate to: Type of median line used Measure used • For each chart, decide what improvements would be most useful, and why. Annotation Design

35. Analysing data: Interpretation of run charts: summary • Annotation • Median • Phasing • Extreme values • Stratification

36. System of Profound Knowledge Deming 2000

37. Visual display of data: using Excel to create run charts • By the end of this session you will be able to: • Create annotated run charts with baseline and extended medians using Excel • Create an annotated run chart showing phasing with Excel

38. A New Healthier Me Aim 1 Driver 2 Driver Change ideas A new healthier me! Lose 7 pounds in 3 months Cook evening meals from scratch Calories in meals Reduce portion size Calories in Calories in snacks Keep to shopping list Replace biscuits/cakes with fruit Calories in drinks Max 1 x juice or soft drink per day Calories in alcohol No alcohol Monday to Thursday Calories out Work activity Get up from desk to talk, instead of phone or email Leisure activity Use stairs not lift Walk to a daily step target Swim at least twice a week

39. Visual display of data • Basic run chart • Run chart with baseline and extended median • Run chart with phasing • Run charts with your data • Annotations.

40. 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.

41. System of Profound Knowledge Deming 2000

42. 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

43. 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

44. 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.

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

46. 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

47. 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

48. 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

49. 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?

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