improvement training winterbourne medicines launch
DESCRIPTION
Improvement training - Presentation from the Winterbourne Medicines Programme Launch held in London on 10 September 2014 Ensuring safe, appropriate and optimised use of medication for people with learning disabilities who demonstrate behaviour that can challengeTRANSCRIPT
Improving health outcomes across England by providing improvement and change expertise
Quality Improvement Training
Zoë Lord & Carol MarleyImprovement Managers
How are you feeling?
What we’re going to cover
• Improvement models & techniques – Mapping– Measuring – Testing & improving…
• Understanding ourselves and others…Getting the right people involved.
Quality ImprovementService Improvement
Service RedesignProcess Redesign
• But there is a clear structure that we’re going to follow, and we’re going to help you.
• Improvement work is not difficult
• It’s not necessary to start from scratch
• It’s pointless to just tell people to work harder;it’s better to try and work differently
“Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way…if only he could stop bumping for a moment and think of it!”A. A. Milne
“Every system is perfectly designed to get the results it achieves”
Paul BataldenDartmouth Medical School, New Hampshire, USA.
The NHS Change Model
8 components
Aims
Measurements
Change ideas
The Improvement GuideLangley et al (1996)
What are we trying toaccomplish?
How will we know that achange is an improvement?
What changes can we make that will result in improvement?
Model for Improvement
Act Plan
Study Do
Testing ideas before implementing changes
PDSA Cycle for Learning and Development
Act Plan
DoStud
y
Act on learning…What is next?
Observe the results… Did it work?
What will happenif we try somethingdifferent?
Try it!
• Ready to implement?
• Try something else?
• Next cycle
• Objective• Questions and predictions• Plan to carry out:
Who? When?How? Where?
• Complete data analysis• Compare to predictions• Summarise
• Carry out plan• Document
problems• Begin data • analysis
Table Discussion
Aims
Measurements
Change ideas
The Improvement GuideLangley et al (1996)
What are we trying toaccomplish?
How will we know that achange is an improvement?
What changes can we make that will result in improvement?
Model for Improvement
Act Plan
Study Do
Testing ideas before implementing changes
We are trying to accomplish…
Safe, appropriate and optimised use of medication for people with learning
disabilities whose behaviour can challenge.
We all need to be talking about the same thing…
Can you picture…
A cat on a mat!!
Mapping the Process
“Every system is perfectly designed to get the results it achieves”
Paul BataldenDartmouth Medical School, New Hampshire, USA
• One of the most useful tools in improvement work• Works within organisations and across organisations• Understand current systems• Identify areas to investigate/change/improve - particularly
‘handoffs’, duplication and “why on earth do we do that?”• steps which do not add value for the patient• Identify process waste• Team-building process - helps shared understanding and
building links etc.
Process and Value Stream Mapping
An elephant is like a brush
An elephant is like a rope
An elephant is like a snakeAn elephant is
soft and mushy An elephant is like a tree trunk
Lift receiver
Dial Number
Let phone ring
Say Hello
Have Conversation
Say Good ByeHang up receiver
Simple Process Maps
Lift receiver
Dial Number
Let phone ring
Say Hello
Have Conversation
Say Good Bye
Hang up receiver
Answered?Yes
No
Start \ Finish
Task
Decision or Choice
Direction of flow
Key
Simple Process Maps
What you think it is
What it actually is
What it should be
What it could be
Versions of a process
Value Stream Map
27 minutes hands on time = 91 days
Value Add, Non Value Add and Waste
Value
UnnecessaryWaste
NecessaryWaste
MinimizeEliminateValue Added Activity
Any activity that changes the form, fit, or function of a product/transaction
— OR —Something customers are willing to pay
for
Non-Value Added Activity•Any activity that absorbs resources but
adds no value is a Waste
1st Step - Defining Value
Maximize
A C E
Diagnostic process
Organisational / Departmental Boundaries
Acute Episode
Treatment process
B D
Analysing a Process Map
Analysing a Process Map
• Are we doing the right thing? (Clinical effective)
• Are we doing them in the right order?
• Is the right/best person doing it?
• How co-ordinated is the patients journey?
• What information do we give to patients at what stage? Is the information useful?
Non Value Add (Waste)
• Clues to Non Value Add…
– Rework– Recheck– Return – Retype– Repeat– Recall– Remeasure– Redo
– Bottlenecks– Delay – Waits– Movement – Audits – Handoffs
S.E.C.S
• Simplify
• Eliminate
• Combine
• Sequence
1 Patient has cardiac catheter
4 Tape sent to post room
CHH
5 Tape sent to post room
HRI
6 Tape sent to secretary at
HRI
7Secretary
types letter
8 Letter to doctor for signature
9Letter signed
10 Letter returned to secretary
11 Letter sent to post room
HRI
12 Letter sent to post room
CHH
13 Letter delivered to secretary
14a Secretary request
angiogram
14Letter to surgeon
15 Letter to secretary for OPD
16 Letter to post room
CHH
17Letter to
appointments
18Letter sent to patient
15a Radiographer finds
angiogram
16a Angiograms given to
porter
17a Angiogram delivered to secretary
3 Tape to ward
clerk
2 Letter dictated to
surgeon
19Patient seen
in clinic
20 Patient put on waiting
list
18a Angiogram reviewed by
surgeon
19a Arteries suitable for
surgery
20a Surgeon considers
patient suitable
Example: Referral and Discharge Letters, Cardiac Catheterisation Lab, Hull Royal Infirmary
…after
1Patient has angiogram
2 Data input into
computer
3 Print out data as referral
letter
4 Letter and angiogram
delivered to secretary
5 Secretary makes OPD appointment
6Patient seen
in clinic
1aAngiogram
Tape
Your event…
Hints and Tips:¨ Define the scope
- what process are you going to map?- what are the start and end points?
¨ Decide who is going to be involved
¨ Walk the pathway / process
¨ Start ‘high level’ - then detail where necessary
¨ Focus on the high volume work i.e. ~80% of the work. This is called the ‘Green Stream’
¨ We’ll be helping you!!! Dates in diaries!!!
“To change an organisation,
the more people you can involve,
and the faster you can help them
understand how the system works
and how to take responsibility for
making it work better, the faster
will be the change”
Martin Weisboard
Training and Development Journal
Measurement for Improvement “All improvement will require change,
but not all change will result in improvement”
Aims
Measurements
Change ideas
The Improvement GuideLangley et al (1996)
What are we trying toaccomplish?
How will we know that achange is an improvement?
What changes can we make that will result in improvement?
Model for Improvement
Act Plan
Study Do
Testing ideas before implementing changes
“It feels like…” “I think …”
just isn’t enough!!
If you don’t measure, you won’t know…
• If the changes we make have actually made a difference
• If it is an improvement• How much difference the change has made • How much variation there is in the data/process• Whether you have achieved your aim• If the improvement has stayed in place?
Top tips when starting to measure:
• Seek usefulness not perfection
• Measure the minimum!
• Remember the goal is improvement and not a new measurement system.
• Aim to make measurement part of the daily routine.
We need a baseline!
• To understand current position• Tell a story• Define success • Before and after comparisons• For evaluation and celebration!!!
Baseline examples
• How many people are on your case load:– With challenging behaviour?– With CB and on medication?– With CB and on medication and had a formal
review?
• How many have had review with a clinical pharmacist?
Developing metrics
• We’re going to help you!
• Process measures
• Measure the demand on the service• Measure your capacity • Measure activity• Measure backlog• Outcome measures - reduction in inappropriate medication
A B
Got the data… what next?
Understanding the information Root Cause Analysis
Problem Solving
Data Analysis• Some people love it – but not everyone does!! But it’s
important!! And we’re going to show you how to do it!
• We want to tell a visual story!
List of data
Before and After Intervention Birmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
NHS Number The Mean (Average) Upper Control Limit Lower Control Limit
Intervention HERE
Data Analysis• Some people love it – but not everyone does!! But it’s
important!! And we’re going to show you how to do it!
• We want to tell a visual story!
• Easy to understand
• A way of demonstrating and thinking about variation – good & bad!
• Statistical Process Control – SPC
What does an SPC Chart look like?Birmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit
NHS Number
Day
s
SPC Chart to show length of time from prescription to review
Run Chart Birmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit
NHS Number
Day
s
Birmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit
NHS Number
Day
s
SPC Chart to show length of time from prescription to review
SPCBirmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit
NHS Number
Day
s
SPC Chart to show length of time from prescription to review
SPCBirmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit
NHS Number
Day
s
SPC Chart to show length of time from prescription to review
AVERAGE
Upper Control
Lower Control
SPCBirmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
Laboratory Number The Mean (Average) Upper Control Limit Lower Control Limit
NHS Number
Day
s
SPC Chart to show length of time from prescription to review
Variation
Time to start asking questions!
Before and After Intervention Birmingham Nov 09 - Gynae - Sample taken to Result issued
-
2
4
6
8
10
12
14
16
Days
NHS Number The Mean (Average) Upper Control Limit Lower Control Limit
Intervention HERE
Root Cause AnalysisProblem Solving
0
10
20
30
40
50
60
70
80
90
F M A M J J A S O N D J F M A M J J A S O N D
Cascading Stratification
Fre
quen
cy
Pareto A
Pareto B
Pareto C
Primary Diagnosis
Ward
Doctor
Kettering General Hospital - Acute myocardial infarction admissions by Ward - Oct 02 to Oct 03
0
50
100
150
200
250
CC
U
MA
U
Alth
orp
ITU
Sur
gica
lad
mis
sion
s
Lam
port
Har
row
den
B
Har
row
den
C Oth
er
Ward transfrred to
Nu
mb
er
0%10%20%30%40%50%60%70%80%90%100%
Count Cum %
Use in combination to validate root causes
Root Cause Analysis• What is it?
– Root cause analysis is the identification of the “vital few” causes that have a material impact on the outputs of a process
• Objectives of Root Cause Analysis– Determine with reasonable confidence what are the current
major causes of problems within a process.
• Why use it?– Too often improvement is initiated based on anecdote and not
rigorous analysis of the facts.– Ensures actions are taken on actual causes rather than
symptoms
Pareto
What does a Pareto look like?
Pareto – 80/20
• Named after Vilfredo Pareto in 20th century who found that 80% of the wealth in Italy was held by 20% of the population
• Helps to focus on the problems which will have the biggest impact if addressed.
• 80% of complaints are about 20% of your services
• Shows relative importance in a simple, visual format.
Fishbone Cause-and-Effect Analysis
Cause 1 Equipment
Cause 2 People
Cause 3 Procedures
Cause 4 Measurement
Cause 5 Communications
Cause 6 Materials
Problem StatementAgree the major
cause categories and attach to the centreline of the diagram
Cause 7 Machines
Cause 8 Methods
Cause 9 Policies
Cause 10 Plant \ Environment
How to construct a fishbone diagram
How can a Fishbone help?
• To help break down a large problem into small elements
• To reveal hidden relationships between causes & effects
• To help identify the root of a problem • To highlight important relationships for investigation • To identify possible data requirements for the project• To help individuals or groups to generate ideas • To identify areas for quick wins
Problem Statement - Why are 51% of patients staying
longer than 5 days ?
Cause 3 ProceduresCause 2 People
Cause 6 Materials \resources
Cause 5 Communications
Cause 4 Measurement
Cause 1 Equipment
No MDT’s
Delays in patient transfer
Transport issues
No hospital wide procedure
No Active discharge planning
Inconsistent recording of ward round requirements
Inconsistent verbal communication on transfer
Transport not available
T.T.O’s not available
Duplication of diagnostics
Limited 24/7 access to diagnostics
Discharge lounge not opened at weekends
No CathLab
POD not working weekends
Work through the main headings drilling down through the causes
We’ve made improvements…
What next?
• Continuous Improvement • Standardisation • Mistake proofing • Sustainability & Spread
We’ve made improvements… What next?
Getting the right people involved an supporting the process of change
Do you like change?
Attitudes to change differ…
Proportionateenthusiasm
Healthyscepticism
Annoyingevangelism
Irrationalobstructionism
Moderateinterest
How do you feel if your not told about changes?
How do you feel if you’re the last to know?
Have you got the right people involved?
• Psychiatrists, nurses, managers, care staff, pharmacists, patients, carers, families, speech therapists, psychologists, commissioners, trust service improvement / project management office, communications team, chief executive, schools, GPs, social services and local authorities …
Attitudes to change differ…
Proportionateenthusiasm
Healthyscepticism
Annoyingevangelism
Irrationalobstructionism
Moderateinterest
Attitudes to change
Proportionateenthusiasm
Healthyscepticism
Annoyingevangelism
Irrationalobstructionism
Moderateinterest
Calming downKeeping in real world
PerspectiveFocussing ?
SupportDirectionFeedback
MotivatingExploring
Evidence of benefit
“Unpacking”Debate (argument)
Selling
Go back to your communication plan…
We all respond differently
• Analyst• Amiable• Social (Expressive)• Driver
Analyst Amiable Expressive Driver
Analytical Patient Verbal Action-orientated
Controlled Loyal Motivating Decisive
Orderly Sympathetic Enthusiastic Problem solver
Precise Team person Gregarious Direct
Disciplined Relaxed Convincing Assertive
Deliberate Mature Impulsive Demanding
Cautious Supportive Generous Risk-taker
Diplomatic Stable Influential Forceful
Accurate Considerate Charming Competitive
Conscientious Empathetic Confident Independent
Fact finder Persevering Inspiring Determined
Systematic Trusting Dramatic Results-orientated
Logical Congenial Optimistic
Conventional Animated
Analyst
The Analyst: Technical SpecialistMay be perceived positively as
May be perceived negatively as
• accurate • critical
• conscientious • picky
• serious • moralistic
• persistent • stuffy
• organised • stubborn
• deliberate • indecisive
• cautious
The Analyst• Places an high value on, facts, figures, data and reason• Sometimes described as analytical, systematic or
methodical• Tend to follow an orderly approach when tackling tasks• Well organised and thorough• Sometimes seen as too cautious, overly structured and
does things ‘by the book’• They view time in a linear (sequential) fashion
How do you communicate
with an Analyst?
Communicating with an Analyst• They want facts, figures and data in the message
• It should be presented in an orderly fashion, with supporting documentation
• Give them time to examine reports etc.
• Written communications can be quite formal and precise, listing key points
Amiable
The Amiable: Relationship Specialist
May be perceived positively as
May be perceived negatively as
• patient • hesitant
• respectful • ‘wishy-washy’• willing • pliant• agreeable • conforming• dependable • dependent• concerned • unsure• relaxed • laid back• organised• mature• empathetic
The Amiable• Interested in & places a high value on, relationships,
feelings, interactions and affiliation with others
• Often described as warm and sensitive to feelings of others, and a loyal & supportive friend
• May be viewed as too emotional / sentimental and too easily swayed by others
• Will often make reference to past events and their relationships over a period of time
How do you communicate
with an Amiable?
Communicating with an Amiable
• Make sure the human dimensions and how people may feel are included
• Let them know who else will be involved• Include past experiences in a similar situation• Written communications can be quite
informal, chatty and friendly.
Expressive
The Expressive: Social Specialist
May be perceived positively as
May be perceived negatively as
• verbal • a talker• inspiring • overly dramatic• ambitious • impulsive• enthusiastic • undisciplined
• energetic • excitable• confident • egotistical• friendly • flaky• influential • manipulating
The Expressive
• Interested in taking people with them, enthusing them with optimism and energy
• Tend to be open with people and willing to make a personal investment
• Generally very good with people• May frighten people by being expressive!• They tend to be poor with detail
How do you communicate
with an Expressive?
Communicating with an Expressive
• They will be looking for the new and the exciting aspects of the message
• Include some kind of innovation to hook the expressive
• Written communications can tend to be vague and abstract.
• They are inclined to be idea orientated and are often quite lengthy in making a point.
Driver
The Driver: Command Specialist
May be perceived positively as
May be perceived negatively as
• decisive • pushy• independent • one man show• practical • tough• determined • demanding• efficient • dominating• assertive • an agitator• risk-taker • cuts corners• direct • insensitive• a problem solver
The Driver• Places great emphasis on action and results• Often viewed as decisive, direct and pragmatic• They view time as here and now, like to get things done
and hate spinning things out• They translate ideas into action, and are dynamic &
resourceful• Sometimes accused of only seeing the short term, and
neglecting long-range implications• Can be seen as too impulsive, simplistic, and acting
before they think
How do you communicate with a Driver?
Communicating with a Driver
• “What are we going to do?”• ‘When are we going to do it?”• Written communications will be brief,
sketchy and crisp.• They may resent having to take the time to
write and will often scribble a reply on the senders original message and return it to them.
Go back to your communication plan…
Today we have covered…
Improving health outcomes across England by providing improvement and change expertise
Next Steps
Next Steps
• Dates in diaries with Zoë and Carol • Complete and return paperwork• Monthly reporting• 6C’s community of practice
• Engage your team• Define your project• Understand your baseline and measures• Patient engagement plans
Remember:
What people should doWhat people think they doWhat people say they do
May not beWhat people actually doUnderstand the real problem before you plan the
solution
Don't make assumptions...
@NHSIQ
www.nhsiq.nhs.uk
Improving health outcomes across England
by providing improvement and change expertise.