Quality Improvement Processes, reliability and capacity

1. Quality Improvement Processes, reliability and capacity Dr. Simon Watson NHS Institute for Innovation & Improvement

2. Mechanics of quality improvement • Define your quality metric • Measure it • Change your system • Check for improvement – re-measure

3. Why do some quality improvement initiatives fail?

4. Because change isn’t easy

5. Major obstacles to change • Habit – what a person usually does • Culture – what an organisation usually does • Successful improvement initiatives change habits and cultures • A strategy to implement these changes is essential

6. Culture Vs Strategy Not a fair fight

7. What is reliability? Reliability Sometimes Always “Reliability means keeping a promise”

8. Reliability Reliability = error free operations total number of operations 90% 99% 99.9% 99.99% 99.999% 99.9999%

9. Reliability in healthcare 40% http://www.aware.md/images/handwashing.jpg

10. Example – the Ventilator Bundle • Elevation of the head of the bed • Daily “sedation vacations" and assessment of readiness to extubate • Peptic ulcer disease prophylaxis • Deep venous thrombosis prophylaxis 

11. RT built into 1 hour scheduled vent checks as a) Integrate daily goals with MDR to identify defects as a Feedback on compliance Education Baseline Example of using 10-1 and 10-2 change concepts to initially reach a reliability of 10-1 then additionally using a robust 10-2 change concept (redundancy) to reach 10-2 reliability in the 4 elements of the ventilator bundle (Baptist Memorial, Memphis)

12. 12 months to achieve 100% compliance with ventilator bundle

13. Implementing change • Measure whether your change is being implemented…… • ……….before you look for improvement • Assume full implementation will take time • Have a strategy to achieve full implementation • Failed change and failed implementation of change are different things

14. Designing reliable processes

15. Human vigilance, memory and professionalism These alone will NOT achieve reliability

16. Designing for reliability • Use protocols whenever possible • Simulate protocols to before use ‘in anger’ • Check lists to support protocol • Automatic alerts – computer screen, emails etc. • Feedback on compliance

17. Key features of protocols • Evidence-based • Lead to good decisions • Easily comprehensible • Readily available • Co-designed with intended users • Process for continuous improvement

18. The limits of process-controlled management

19. Common cause variation

20. Special cause variation

21. Types of variation Special cause variation = Unusual variation Managing special cause variation:- • Suspend protocol • Get expert input

22. CapacityThe maximum work that can be done in a given time

23. Management Charge Nurse Specialist Nurse Junior C/N Staff Nurse Consultant Cons. Deputy

24. Traditional process

25. Treatment Nurse effects Doctor adjusts Nurse tells Nurse gets Result Blood test Change to prescription doctor result published performed treatment Do all steps add value?

26. A ‘lean’ process Treatment Nurse effects Change to treatment Nurse gets result Result published Blood test performed Special cause variation “Expert”

27. Management Charge Nurse Specialist Nurse Junior C/N Staff Nurse Consultant Cons. Deputy

28. Summary • Great improvement plans aren’t enough • Plans are completely dependant on the processes that deliver them • Recognise that change is challenging • Finally……

29. THINK • PROCESS • RELIABILITY • CABABILITY

30. Simon Watson simon.watson@institute.nhs.uk simon.watson@nhs.net 0796 991 6068

31. END

33. Test performed Nurse gets result Result published Dr. changes script Nurse tells Dr result Change effected

34. Basic process diagram Treatment Optimise treatment Test efficacy (blood test)

35. Improvement plans are likely to fail if they aren’t implemented reliably