Quality Improvement Neil Houston GP Clinical Lead SPSP – PC Associate Adviser NES

1. Quality Improvement Neil Houston GP Clinical Lead SPSP – PCAssociate Adviser NES

2. Aims • What is QI • A method of how to do it • Develop your own ideas • Preparing for the real world

3. Insanity: doing the same thing over and over again and expecting different results. Albert Einstein, (attributed) US (German-born) physicist (1879 - 1955)

4. What is QI? “the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to: better patient outcomes better system performance better professional development”

5. Healthcare will not realise its full potential unless change making becomes an intrinsic part of everyone’s job, every day, in all parts of the system. Doing the work and working on the work

7. The Model for Improvement • ‘This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement’ • Dr Donald M. Berwick • Former Administrator of the Centres for Medicare & Medicaid Services • Professor of Paediatrics and Health Care Policy • at the Harvard Medical School

9. Question 1: What are we trying to accomplish? Developing the team’s Aim Statement

10. Aim Statements • Specific • Measurable • Achieveable • Realistic • Timely

11. Aim Statements You Make the Call!

13. “I want to be seen at or near to my appointment time”

14. Aims 95% of patients attending the Opthalmology outpatient department at Forth Valley Royal Hospital will be seen by a clinician within 15 minutes of their appointment time by October 2016

15. Developing an Aim Statement Team name: Aim statement You should review your Aim Statement frequently to make sure it is consistent and that everyone involved with the initiative has a common understanding of what is to achieved. How will this be measured ? By when?

17. “In God we trust. All others bring data.” W. E. Deming

18. Change vs Improvement Of all changes I’ve observed, only about 5% were improvements, the rest, at best, were illusions of progress W. Edwards Deming

19. Why are we measuring? Research Improvement Judgement The answer to this question will guide our entire measurement journey

20. Measurement for judgement % waiting over 4 hours in A&E England by week 2003/04 target The week Trusts were measured for performance ratings

21. So why measure? To enable us to ‘see’ how we are doing To enable us to ‘see’ the variation that lives in our daily processes To tell us whether we are getting closer to our aims? What are we doing well? Why What are we not doing so well? why?

22. Three Types of Measures Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result? Warfarin Control – Reduction in number of strokes Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned? Warfarin – are patients in therapeutic range and appear for bloods tests Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome) Warfarin – number of blood tests taken

23. What could you measure? ” • Patients will be seen within 15 minutes of their appointment time • Data for average time after appointment time that patients are called into the clinicians room • How • IT • Observation • Questionnaire What could you measure

24. How often should you measure?

25. We have 2 quarterly data points – is this an improvement? Higher is better

26. Are we assuming something like this? Measurement for Improvement

27. But it could be like this ... Measurement for Improvement

28. Or this ...

29. Or this!

30. PLOT Data over time

31. Run chart • A run chart is the simplest of charts. It is a single line plotting some value over time. A run chart can help you spot upward and downward trends and it can show you a general picture of a process.

34. How big a sample?Little and often What would your measurement plan look like ?

36. What changes are to be made? Next cycle? Aim & plan the cycle (who, what, when & how) Compare/analyse data, Summarise learning Carry out the plan Document problems

37. Anyone for tennis?

38. Instructions • At your tables 6 - 9 people • Assign a time keeper • Assign a number to each of the other people at your table

39. Break out Exercise • Your current process involves tossing the tennis ball (provided) from person to person, following the sequence provided on the next slide Practice your process one time Time keeper please: • Time how long the team takes to complete the process (in seconds) • The number of times they drop the tennis ball

40. Exercise Sequence 9 people 8 people 7 people 1 1 1 1 1 5 people 4 4 4 5 3 9 8 5 6 7 3 3 3 2 3 7 6 7 4 5 2 2 1 2 5 2 6 1 5 6 4 1 1 6 people 1 8

41. Time? Drops?How low can you get?

42. Break out Exercise Team Aim: We aim to reduce the time taken for every person to touch the ball in sequence. We also aim to reduce our ball drops Rules: • The initial sequence as provided must be adhered to • You may only test one change idea at a time • Record the time and ball drops after each change

43. Exercise Sequence • 9 people • 8 people • 7 people 1 1 1 1 1 • 5 people 4 4 5 4 3 5 7 9 8 6 2 3 3 3 3 4 7 5 6 7 1 2 2 2 5 2 1 6 5 6 4 1 1 6 people 1 8

44. How did you get on ?Fastest Time ? Breakthrough Changes?

45. What changes are to be made? Next cycle? Aim & plan the cycle (who, what, when & how) Compare/analyse data, Summarise learning Carry out the plan Document problems

46. Building Knowledge with PDSA Tests A P S D D S P A A P S D A P S D Breakthrough Results Evidence and data Wide-scale tests of Change Tests under new conditions (Quantitative data) Follow-up Tests Hunches, Theories, Best Practices Very Small Scale Test (Qualitative/Quantatiative Data) Improvement Guide, Chapter 7, p. 146

47. A typical approach Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. Available: www.ihi.org p26

48. An Applied Science Approach Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. Available: www.ihi.org p26

49. You can only learn as quickly as you test.

50. The Value of “Failed” Tests “I did not fail one thousand times; I found one thousand ways how not to make a light bulb.” Thomas Edison