phil duncan and ian chappell collaborative launch

Improving health outcomes across England by providing improvement and change expertise

Phil Duncan, Patient Safety Collaborative Lead, NHSIQ

Ian Chappell, Improvement Manager, NHSIQ

A system based on continual learning: a (brief) guide to using measurement for

improvement

#saferNHS

What do we mean by continuous learning?

‘The single most important change in the NHS … would be

for it to become, more than ever before, a system devoted

to continual learning and improvement of patient care, top

to bottom and end to end’

The Berwick Report (2013), 'A Promise to Learn - a Commitment to Act'

“Every system is perfectly designed to get the results it achieves”

Paul Batalden Dartmouth Medical School, New Hampshire, USA.

The process for improvement

Implementation or testing: the 3 Reasons for Measurement

Source: Robert Lloyd IHI 2006

Learning – a system

Every day skilled healthcare professionals face challenges with basic defects and flaws that make it difficult to deliver high quality care • A learning system provides a methodical way

to visibly capture concerns, act on them, introducing a cycle of learning and improvement

• This is an essential component of high performing organisation

Critical components of a learning system are Reliability, Improvement and Measurement

and Continuous Learning Processes

©Alan Frankel and IHI 2013

Improvement & Measurement

Where there is a culture of continuous improvement and learning typically we see • Clearly identifiable aims – “how much

by when” • Links between strategy and action –

e.g. driver diagram • Frequent testing of improvement

ideas - and evidence of learning (PDSA’s)

• Measurement systems – process, balancing and outcome

• Transparency - visibility of data– run charts etc


Continuous Learning

High performing teams build in the capacity for improvement at a local level • Transparency - have a clear, reliable

process to identify defects – e.g. learning boards

• Ensure someone owns the problem and is fixing it in a timely manner – this can rapidly build trust and drives local improvement

• Regularly feedback to those who identify defects

• Getting the basics right


Reliable Process

“The ability of a system to perform it’s intended function under commonly occurring conditions” • Example of high reliable organisations –

Airline industry, nuclear substations Deliberate design makes processes reliable • Getting the basics right first time every

time by testing, refining, re-testing • Reduce variation – simplify and standardise • Regularly problem solve – e.g. RCA, AAR Factors that affect reliability • Individual autonomy – e.g. ‘difficult’ staff

member • Human factors – deviance, culture • Over reliance on training or policy


How do we currently measure safety?

The Current Way The New Way?

How safe is the NHS?

Last year there were 15 million hospital admissions compared to 320 million episodes of care in primary care. In the last 6 months NRLS reporting suggests that 74% of all incidents are reported by acute/general hospitals.

How do we measure safety improvement? Safety Concern

National Data Sets

VTE Y

HCAI Y

Pressure Ulcers Y

Medication Errors Y

Deterioration N

Falls Y

Handover & Discharge N

Nutrition & Hydration N

AKI N

Sepsis N

Missed/Delayed Diagnosis N

Measurement for Improvement capable

Y/N

Y

Y

N

N

Y/N

N

N

N

N

N

5 key principles of measurement for improvement

• Priority Setting and Baseline development - Use available outcome and process data to understand current areas

for improvement. Where it doesn’t exist review the last 5 patients and speak to care givers, patients and carers.

- Use tools like Pareto to understand where the burden lies - Look at outcome and process data over a period of time to look for

changes

• A small number of operationally defined measures - Choose between 6-8 measures that cover the aim of your

improvement (outcome) and the things you intend to change to achieve an improvement (process).

- Ensure that everyone involved understands what they are collecting, that the measures are well defined along with the population in focus.


• Understanding variation through regular measurement over time - Avoid static before and after measurement. You will learn more from regular measurement over time. - Learn from variation (Shewhart) and use tools like run charts and SPC to analyse the data

• Smart analysis: how to cut the data to provide learning - Think about how you can analyse your data for greater learning e.g.

by demographic, by setting type, by time etc. - Utilise numerous data sources and types to triangulate. This will

provide a better understanding of what’s happening


• Qualitative Review: using regular reporting to provide theories of change - Don’t just use quantitative data. Whilst it aids outcome and process

measurement, it hides potential learning about how change happens.

- Use qualitative data to supplement your other improvement measures e.g. board reports, meeting notes, interviews etc.

Summary

• Continuous Learning often exists, but is powerless without a ‘safe’ organisational culture

• There are a number of measures of safety nationally but few are suitable for measuring improvement

• Safety measurement requires a balance of outcome and operational awareness

• Measurement for improvement is about knowledge and learning from variation

Any questions?

[email protected]

[email protected]

#saferNHS

phil duncan and ian chappell collaborative launch

Healthcare