Methods for Improvement Where is the Will?

Methods for Improvement Where is the Will?

Methods for Improvement Where is the Will? David I Gozzard Annette J Bartley NHS! Improvement Mantra Will Ideas Execution ..then Scrutiny WILL The mental faculty by which one chooses or decides upon a course of action The act of exercising the will Diligent purposefulness; Determination Self-control; Self-discipline A desire, purpose or determination, especially one

in authority Free discretion, inclination or pleasure Bearing or attitude towards others; disposition Problems around Will Data Somebody else's data, doesnt relate to my clinic or practice Discomfort Discomfort Zone Denial/Disbelief Nothing wrong with my practice Its the uniqueness of my patients Clinician Comments Too busy..admin and over-busy clinical time Its a nursing thing I just deal with my own patients Quality suffers because of the outliers, lack of junior staff,

the lack of continuity SPI is just around the margins I am not paid to do this My cases are high quality its the other ward that is dirty Things are not like they used to be - we used to work harder and be more vigilant No clear vision from Government yet another initiative Its not in the targets set by my General manager I dont believe the data You have gone over to the dark side Improvement Culture: A Useful Guide Every enterprise has four organisations: the one that is written down, the one that most people believe exists, the one that people wished existed and finally, the one that the organisation really needs

NHS Chief Executive The Discomfort Zone Comfort Zone: People stay here, dont change, dont learn Discomfort Zone: People uncertain, but most likely to change, most likely to learn Panic Zone: People freeze, will not change, will not learn To encourage people to leave a comfort zone, you need to help them feel safe. You can do this by creating the right environment and culture, ensuring that there is no blame. The Individual: Readiness to Change Descriptor Behaviour Action

Pre-contemplation The individual is not ready to discuss or consider change Consciousness raising Contemplation The individual is willing to listen and to consider a change Emphasis on benefits Preparation The individual gets ready to do something concrete

Provide support Action The individual starts to work with Continue support in the change addition to encouragement and praise Maintenance The individual strives not to slip back to old behaviours Scrutiny of process? Prochaska et al 1992 The Nature of Change

Change can be.. Collective Everyone in a group must decide to adopt or not Authoritative The individual is told to adopt Contingent The individual cannot choose to adopt until the organisation has sanctioned it The Scepticism Continuum Scepticism: The questioning or doubting of accepted opinion Resistance: Through actions and arguments prevent someone from doing

something, or prevent something from happening behaviour attitude behaviour active resistance passive resistance scepticism neutrality acceptance commitment active

involvement The Value of Resistance Commercial practice, for example, often interprets resistance to change as a natural and necessary force for exposing and resolving conflict, and consequently for planning and implementing change effectively. Mabin et al 2001 Organisations need resistance to change in order to prevent bad and poorly developed ideas from being implemented. Schn 1963 The Involvement Conundrum Impact on personal status, patients and the organisation

Political considerations The individual contemplating change Timing Impact Complexity The proposed change Degree of information or understanding

Skills required Focus Time Context Priority Source Conwy and Denbighshire NHS Trust Conwy and Denbighshire NHS Trust was located in a picturesque rural setting between the mountains and the sea serving a varied population with high percentage of elderly patients. Approximately 900 beds and over 5500 staff. The organisation ran nine hospital sites within a twentymile radius covering Acute, Community & Mental Health services.

Session Outline Where were we in 2004? Our initiation into patient safety Getting buy-in Setting off on the journey Networking Measuring success To spread or not to spread? What does success look like? Anticoagulant Safety 120

Incidents per 100 patient years 100 80 60 40 20 0 1 1.5 2 2.5 3 3.5

4 4.5 5 5.5 Intensity of Anticoagulation (INR) 6 >6.5 Total INR Workload 3000 Tests/month 2500

2000 1500 1000 500 0 1992 1993 1994 1995 INRs 1996 1997 Survey of GP Practices INRs in 1 month

Test:Patient Ratio Number of Patients 5 160 140 4 120 100 3 80 2 60 40

1 20 0 Ratio Patients 0 INR Requests Per month Computer dosing Year Your INR result on Tuesday

9 September 2004 was 3.0 This result was in range. Take your WARFARIN as follows: 3mg daily just as you are doing now Your next test date is 7th October 2004 Dr J Jones A N Other Surgery Mr D Jones 26 Bryn y Castell Abergele Conwy Anticoagulant Control % % INR > 7.0 per month 2.5

2 1.5 1 0.5 0 March April May Dawn June GP July August

Other Safety Projects Medical Devices Robust Consent Process Side/Site Preoperative Marking Clinical Alerts Risk Management was our business Risk Assessments performed widely Open no-blame culture Critical Incident Reporting Root Cause Analysis Links via CEO to NPSA

Good Governance Structure Pre-2002 Clinical Governance Structure Concerns Raised about Reporting Arrangements Commission for Health Improvement visit (CHI) 2002 Difficult to determine which committees are advisory and which are executive Evidence of working in silos Good reporting up the organisation but downwards? Radical re-think!! STRATEGIC LEVEL APPENDIX A Trust Board Clinical Governance

Committee Conwy and Denbighshire NHS Trust Clinical Governance Committee Structure Trust Management Team TRUST LEVEL HR / Education Risk DIVISIONAL LEVEL Medicine CG Steering group

Surgery Governance Steering group Quality, Audit & Effectivenes s Community CG Steering group Research Patient & Public Partnership Women,

children Steering group IM & T Mental Health CG Steering group D I R E C T O R A T E S D&T Clinical Support CG Steering

group Diagnostic support CG steering group T r u s t C o m m it t e e R e p o r t in g S t ru c t u re T r u s t B o a rd A u d it C o m m i t t e e R e m u n e r a t io n C o m m it t e e C li n ic a l G o v e r n a n c e C o m m i t t e e C h a r it a b le F u n d s TMT

L ife lo n g L e a r n in g & D e v e lo p m e n t R e c u it m e n t & R e t e n t i o n W o r k f o r c e P l a n n in g G r o u p R is k M a n a g e m e n t O p e r a tio n a l R is k G r o u p B u lly in g & H a r r a s s m e n t G r o u p C lin ic a l A u d it & E ffe c tiv e n e s s P u b li c & P a t i e n t I n v o lv e m e n t IM & T ( N T O C ) N e w T e c h n o lo g i e s O v e r s e e in g C o m m itte e

I n t e r n a l R e v ie w P a n e l P a t i e n t I n f o L e a fl e t G r o u p H e a lth R e c o r d C o m m itt e e Q u a l i t y D e v e lo p m e n t F o r u m N u r s in g R e s e a r c h S tr a te g y G r o u p K n o w in g O u r C o m m u n i ty C l i n i c a l I n fo r m a t i c s C o m m i t t e e N S F T a s k & F in is h G r o u p s T r u s t R & D S tr a t e g y G r o u p P a t ie n t ' s G r o u p

F .M .S C o m m itt e e F a ll s S t e e r i n g G r o u p I n t e l l e c t u a l P r o p e r ty G ro up G o o d P r a c t ic e T e c h n i c a l/ C o m m s S y s t e m C o m m it t e e M o n i t o r i n g & E v a l u a t io n I n f o r m a t io n S e c u r i t y C o m m i t t e e I n c . C a ld i c o t t s u b g r o u p Y o u n g P e o p le 's F o r u m D e p a r t m e n t a l S y s t e m s C o m m it t e e P e rs o n al

In ju ry JSC C R e s e a r c h & D e v e lo p m e n t O c c u p a t i o n a lH e a lt h & S a f e t y C o m m itt e e H e a l t h P r o m o t io n S t e e r i n g G r o u p M e d ic a l D e v ic e s H R T a s k T e a m / P o li c y D e v e lo p m e n t G r o u p D & T M e d i c a t i o n I n c i d e n ts M o n it o r in g G r o u p O th e rs F r e e d o m o f In f o rm a tio n

A g e n d a fo r C h a n g e P r o je c t B o a rd P r o je c t T e a m D e c o n t a m in a t io n M a d a to r y T r a in i n g G r o u p T e r m s & C o n d itio n s K n o w le d g e & S k i l ls F r a m e w o rk C l in i c a l R i s k G r o u p N V Q G ro up W e ls h L a n g u a g e C o m m itt e e E L e a r n in g G r o u p

E q u a l O p p o r t u n i t ie s S t e e r in g G r o u p H R . IT G ro u p I n f e c t io n C o n t r o l R e s u s C o m m it t e e R a c e E q u a l it ie s S u b - G r o u p R a d ia t io n P r o te c tio n C h i ld P r o t e c t i o n O r g a n R e t e n t io n G r o u p C o m m u n ic a t i o n S t r a t e g y G ro up E m e r g e n c y P la n n in g G r o u p

W e l s h R is k P o o l S ta n d a r d s L e a d s C o m m u n ic a t io n s H e a d s o f N u r s in g C o m p la in t s & L itig a tio n B lo o d T r a n s f u s io n R C N C li n i c a l L e a d e r s h i p / L e a d e r s h ip G r o u p C a l d i c o tt G r o u p J o b M a t c h in g PLUS in p u t f r o m D i v is io n a l le v e l

g r o u p s t o a ll c o r p r o a t e c o m m it t e e s a s r e q u ir e d C o m m i t te e s w i t h o u t c l e a r r e p o r tin g s tr u c tu r e s : F u n d a m e n ta ls o f C a re N u r s i n g P r a c t i c e & E d u c a t io n - F a c ilitie s - M e d ic a l a n d S u rg ic a l S u n d r ie s - T a s k & F in is h G r o u p s e .g . H o s p ita l a t N i g h t s u b - g r o u p N u r s in g a n d m id w ife r y r e v ie w p ro je c t T h e a tre s W a itin g L is t s C lin ic a l le a d e rs p r o je c t

A d a p ta tio n p r o g r a m m e e tc C li n ic a l S u p e r v i s i o n S te e r in g G r o u p C o n s e n t G ro up The Risk Matrix What are the Trust Incident Reporting Levels? Modernisation Team Modernisation Agency Innovation in Care Significant Projects: Day Case Hernia Pathway Theatre Modernisation Endoscopy Project Access Modernisation

Significant Change Culture Starting Off Getting Buy-In Core Team Members 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

15. 16. 17. 18. 19. Gren Kershaw - Chief Executive Ian Bellingham - Executive Director of Operations Dr David Gozzard - Medical Director Professor Bhowmick - Senior Clinician Professor David Jones - Non Executive Director Jill Galvani - Executive Nursing Director Annette Bartley - Modernisation Manager Debbie Doig-Evans - Integrated Care Pathway Facilitator Jean Ryan - Clinical Librarian David Casey - Infection Control Carol Westwell - Medical Ward Sister Ron Pope - Charge Nurse Operating Theatre Salah Bastawrous - Consultant Orthopaedic Surgeon Diane Read - Orthopaedic Ward Sister Sue O Keeffe - Sister Intensive Care Unit

Philippa Rogers - Clinical Pharmacist Don Hughes - Chief Pharmacist Dr Brian Tehan - Clinical Director Anaesthetics Theatre & Intensive Care Cathy Howe Head of Clinical Governance Project Management Executive Management Team SPI Leadership Team SPI Project Team Measurement/ Information Support Team Pilot / Front Line Teams Wards Perioperative Critical Care

Medicines Management Front Line Pilot Teams Systems Leader Day to Day Manager Executive Champion What did the initiative look like? Wake-up Call! Comfort Care Non Comfort Care ICU HDU

Admission Admission Box 1 Box 1A 0% of deaths 0% of deaths Box 3 0% of deaths Box 3A 14% of deaths Ward Admission Box 2 4% of deaths Box 4 82% of

deaths A Clear and Compelling Measurement System Concept of Adverse Events Trigger Tool used to identify events But many events not recorded! Post-operative pneumonia In-hospital thromboembolism Bleeding on warfarin Medication errors So Risk Procedures were not identifying significant patient harm! Errors and harm - are they the same thing? Harm caused by normal care Harm

Errors that harm the patient Errors that cause no harm to the patient (Near Misses) Errors National Leadership and Innovation Agency for Healthcare Harm Every system is designed to produce the outcome it gets We have systems of care designed to produce certain levels of harm

These levels of harm have become acceptable as a property of the system All harm is theoretically preventable Errors: Failure of a planned action to be completed as intended Error of execution Use of a wrong plan to achieve an aim Error of planning Insights From Using the Mortality Diagnostic Insights Gained from use of Trigger Tool 1) DVT following admission 2) Patient readmission to hospital within 30 days with deterioration of existing co-morbidities 3) Grade 3 decubiti pre-admission. 4) Cardiac arrest at home

5) Cardiac arrests during admission. 6) Readmission within 30 days Warfarin therapy with femoral embolus 7) Patient fell prior to admission 8) PE during admission The Trigger Tool The Trigger Tool What Could we Measure? Performance management requirements Contractual items Number of patients Patient episodes Trends in attendances Waiting times Number of critical incidents These were not

linked Incident reporting and categorisation Why are you measuring? ? h c r a e s e R Ju dg me nt?

Improvement? The answer to this question will guide your entire quality measurement journey! 46 The Three Faces of Performance Measurement Aspect Improvement Accountability Research Aim Improvement of care Comparison, choice, reassurance

New knowledge Methods: Tests are observable No test; merely evaluate current performance Test blinded or controlled tests Accept consistent bias Measure and adjust to reduce bias Design to eliminate bias Sample Size

Just enough data, small sequential samples Obtain 100% of available, relevant data Just in case data Flexibility of Hypothesis Hypothesis flexible, changes with learning No hypothesis Fixed hypothesis Sequential tests

No tests One large test Determining if change is an imrovement Run charts or Shewhart control charts No change focus Hypothesis, statistical tests Confidentiality of the Data Data used only by those involved with

improvement Data available for public consumption and review Research subjects identities protected Test Observability Bias Testing Strategy Bob Lloyd, IHI 47 Measuring Quality No system in place to measure quality What are our quality indicators? Data for performance management

Data for research Data for quality improvement 40 measures Each required a new system to measure Mostly via laborious case note audit But it had to be done! Quality Aims Patient Centeredness Patient Safety Efficiency Effectiveness Timeliness

Equity Networking and Leadership Team Structure: Day to Day Lead Systems Lead Executive Lead Early progress: Leadership Safety Walks schedule prepared PDSAs tested Safety Walks in the pilot sites

Extended to the rest of the organisation Feedback system undergoing initial tests. Small number of Safety Walks undertaken one planned each week. Patient Safety Coordinator Post advertised First post of its kind in Wales. Before and After Safety Briefings: Orthopaedic Ward Theatres Leadership Safety Walks

Leadership Development SPI FOR SPI Successful Persuasion & Influencing Strategy development day Involvement of New Divisional Management and key leaders Learning Sets planned to spread SPI and develop leadership skills in key staff To Spread or Not to Spread? Why Do Projects Fail? Traditional Approach to Introduction of New Ideas Usually imposed from on high Piloted in one area usually where there are clinical enthusiasts for the project

Works here will work anywhere Spread to the entire organisation by dictat 12 months later it is as if it never had existed! The Safer Patient Initiative Approach Slow, slow, quick, quick, slow Overcoming The Need For Perfection Strategy A Form the committee of experts Spend at least 6 months and many hours developing the perfect solution Educate all the staff over 23 days Implement house-wide tomorrow Look for it in 12 months!

Strategy B Stack the deck 1 doc, 1 nurse, 1patient, one PDSA Reassess and learn from initial test Repeat, progressively increasing confidence in solution then. Test under varying conditions before. Spread Small Scale Tests of Change One patient One doctor One nurse One day / shift

The Spread 1 3 5 S P R E A D The Battle Plan Nov-05 At the start of the campaign develop your strategy for spread

Use the timeline to allocate resources such as ward transformation teams Be realistic in your expectations Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06

Aug-06 Oct-06 SPI Sep-06 com pleted Apr-06 May-06 Jun-06 Jul-06 Aug-06 Oct-06 SPI Sep-06 com pleted PERIOPERATIVE MANAGEMENT DVT Prophylaxis

IHI Expectation Trus t Beta Blocker Use IHI Expectation Trus t SSI Bundle IHI Expectation Trus t SBAR IHI Expectation Trus t Safety Huddles IHI Expectation Trus t MEDICINES MANAGEMENT Reconciliation (all points) IHI Expectation Trus t Anticoagulation Managem ent IHI Expectation Trus t

FMEA of High Risk Process IHI Expectation Trus t CRITICAL CARE Ventilator Bundle IHI Expectation Trus t Central Line Bundle IHI Expectation Trus t Multidisc Rounds IHI Expectation Trus t Daily Goal Sheets IHI Expectation Trus t INFECTION CONTROL/MRSA Isolation/Cohorting IHI Expectation Trus t Hand Hygiene

IHI Expectation Trus t LEADERSHIP W alkRounds IHI Expectation Trus t GENERAL W ARD Safety Breifings IHI Expectation Trus t SBAR IHI Expectation Trus t Early W arning System/RRT IHI Expectation Trus t MEASUREMENT SYSTEM IHI Expectation Trigger tool In place for all interventions

Used to m eas ure harm throughout Trus t Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Legend Tested and im plem ented on only one ward Tested and im plem ented on one half of the wards or eligible patients Tested and fully im plem ented on all wards or all eligible patients What Does Success Look Like?

Adverse Event Rate WashYourHands Campaign MEWS incorporated into TPR chart through out trust General Ward Success Increase in compliance with hand hygiene across the trust % Compliance with Hand Hygiene Medical Wards Poster Campaign

Some staff aware of audit External audit by ICT Meeting between ward consultants & juniors General Ward Team Success Rapid Response Team Daily audit of MEWS in 3 other wards Started to audit compliance with MEWS daily on AMU MEWS on TPR Charts Crash Call Rate

MEWS on TPR Charts Perioperative Success Normothermia Spread through main theatre suite Started to spread to peripheral hospital Perioperative Success DVT Prophylaxis Introduction of DVT assessment tool into pilot area 16 14

12 8 Mar-06 Feb-06 Jan-06 Dec-05 Nov-05 Oct-05 Sep-05 Aug-05 Jul-05 Jun-05 May-05 Apr-05 Mar-05 Feb-05 Jan-05 Dec-04

Nov-04 Oct-04 Sep-04 Aug-04 Jul-04 Jun-04 May-04 Apr-04 Mar-04 Feb-04 Jan-04 Dec-03 Nov-03 Oct-03 Sep-03 Aug-03 Jul-03 Jun-03 May-03 Apr-03 Mar-03

Feb-03 Jan-03 Dec-02 Nov-02 Oct-02 Sep-02 Aug-02 Jul-02 Jun-02 May-02 Apr-02 Moving Average low confidence high confidence Mean Length of Stay (days) MultiDisciplinary Rounds & Goal sheets

VCB CVC B 10 Days ICU Average Length of Stay 20 18 6 4 2 0 Time Period Critical Care - Success

30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% ITU Mortality Hospital Mortality Pre VCB 21.20%

30% Post VCB 16.40% 26% Medicine Reconciliation Post Pharmacy intervention

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