Transcript Document

Agenda
Part 1: The benefits and limits of Top Down Change
Lessons learnt from establishing and managing the National Clinical Programmes
Part 2: Relearning how to use improvement tools in health care
Measurement: Hip Fracture Pathway & ECHO Utilisation
Mapping patient flow: Dementia Pathway
Influencing change: Chemo Drug Savings
Part 3: Observations on teaching clinicians QI
RCPI Diploma in Leadership & Quality
Part 4: Sustaining change
Building a Directorate Model that imbeds continuous improvement
Close: 5 years “Learning” on a page
Key Improvement tools
95%
5%
Data
analysis
Flow
analysis
Change
Management
Process mapping 410-411
Stakeholder Management (Chp 8)
Measuring Variation
Identifying waste
Communication planning (Chp 8)
Illustrating
•Run Charts (Chp 2 & 3))
•Pareto charts -436-437
Influencing styles
Q: Why do we measure?
A: To influence behaviour
In Health care,
the Art of measurement
is as important as
the Act of measurement
Students use of time 12hrs before 15 page essay due
Writing
Formating
page
Making cover
page
Skimming
research notes
Crying due
to fear of
failure
Facebook
Charles Joesph Minard's graphic depicts Napoleon's Army's march from Paris to Moscow. The width of the gray striped
area is the size of the Army going to Moscow, placed over a geographic map. Notice how the width of the band shrinks,
especially when crossing rivers. The solid black area/line reveals the size of the Army returning to Paris.
The bottom line graph displays the temperatures encountered on the return. French casualties in Moscow were light. Yet
the Army was consumed in the march. Only 10,000 of the original 432,000 survived.
Measures
Outcome Measures = Yo
• Measure of project Aim - Voice of the customer or patient. How is the system
performing? What is the result?
Process Measures = X
• Voice of the workings of the system. Are the parts/steps in the system performing as
planned?
Balancing Measures = Yb
• 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)
Yo = f (X , X , X , …………….X ) But  Yb
1
2
3
n
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
Yo = f (X , X , X , …………….X )
1
2
3
Measure & illustrate “Y”
- the
measure of your aim
Run charts
n
May-Aug 2012 average activity
(No. of Patients seen)
Individual activity MayAugust 2012
Why is understanding Variation important
Frequency
e.g. No. of
Patients
B
Aim
A
No. of patients
experiencing a level
of care outside the
desired standard
Distribution
e.g. Avlos
Hospital A & B have the same average performance
But patient experience in Hospital A is much more varied than in hospital B
13
Yo = f (X , X , X , …………….X )
1
2
3
Measure & illustrate “X”
- the
causes of variation
Bar & Pareto charts
n
Reasons for Delays Theatre 10/11: 5/8/14 to 14/8/14
Reasons for delays through out the Day - Theatre 10 & 11
Within our control Vs not in our control
16
Illustrating causes of variation: Pareto & Bar Charts
Count of
frequency of
reasons
Reasons as a % of
total count of
reasons
X1
X2
X3
X4
X5
X6
X7
X8
Y = f(X1, X2, X3, X4, X5……Xn)
X9
X10
Fix the critical X
first – then move
on to PDSA’s for
other Xs
Which is the critical X – the factor that causes the greatest level of variation?
1.
2.
3.
4.
Reorder data with the most frequent reason at the top
Calculate what % each reason type is of total reasons
Create Bar chart of count of reasons
Overlay with line chart which accumulates % of reasons
Frequency
Reason for delayed discharge
Home care package decision
House being adapted
Fair deal delay
Medical Complications
Familly decision awaited
No response from Physician
Count of
reason
5
1
25
5
11
6
53
%
100%
30
25
90%
80%
70%
20
15
60%
50%
40%
10
30%
20%
5
10%
Measurement Plan
Measure title X
Operational definition
or
Y
Medication
Y An adverse (drug) reaction is a
error
response to a medicinal product
which is noxious and unintended
Data source
Medication
error reports
Sample Who When?
size collects?
30
Ward
incidents nurse
How?
Display type?
Start Review
Run Chart
1/5/14 reports end showing trend
of week
by day
Bringing “X” & “Y” together
- to tell a story ”
Hip Fracture Pathway
117Hrs
:Echo
requested
by
Anaesthesi
a
59Hrs:
Ortho.
awaited
cardiolog
y RV
98Hrs: MR
within 24hrs,
waited for
bone scan
72 Hrs:
NOAC,
rivaroxiba
n held
66 Hrs:
Medically
unfit
77Hrs: No
Reason
logged
65 Hrs:
No
Reason
logged
Reasons for variation can be hidden
Note: Times were an ECHO
test was done but the report
was not written up till hours
later have been excluded as
they would eschew the data
incorrectly .
Actual utilisation rate = 65% (Two machines)
The level of variation is +/- 12%
(Note the third machine is not used)
Calculation
The Actual Utilisation time is calculated based on:
The recorded total time for patients in and out plus
the time to complete the ECHO report.
Where there was no time recorded or there was a
significant gap between doing the ECHO test and
completing the report the median time (17 Mins to
test, 11 Mins to report) was used instead
The Potential time was estimated at 13 Hrs for the
two machines per day – formula below
Model for estimating potential utilisation time
Work day (8:30-16:30)
8 Hrs
Less Lunch
1 Hr
Breaks x 2
No. of Hrs if one machine
utilised 100% of time
30 Mins
01:30
06:30
X2
No. of Hrs if two machines
utilised 100% of time
13:00
Consequences of variation
• Wait list for other outpatient ECHO referrals = 800
•
•
Patient safety
Delayed care = impaired outcomes
• Patients kept as In Patients just for ECHO = Bed days lost = ?
•
Anecdotal 1 patient = 7 Days
• Delays in access to surgery and theatre late starts?
•
•
Hip Fractures
Theatre 10 & 11 late starts
• ECHO technician team working through lunch and risk of general burn out
• Combination of unstructured work and environment impacts motivation of key
staff
• NOTE: Patients do not experience delays waiting outside the ECHO room
–
(1 exception due to miscommunication between Secretarial staff & ECHO team)
ECHO/ECG Technician WTE & Competency
•
•
•
•
•
•
Key points:
WTE at 76% of capacity
Approval to fill open vacancies
but if not skilled new joiners will
require training
Approval for HCA – HCA will
improve work environment but
not improve capacity significantly
68% of available team not trained
in ECHO – prevents rotation
between ECG & ECHO plus over
reliance/preassure on Chief
Technician to both train and do
ECHOs
24% of total WTEs (12.5) can do
ECHOs unsupervised or with
minimum supervision
Reasons for
varition: ECHO
Driver Diagram
Key reasons
Primary Drivers
The number of ECHO
machines available
Target Areas of
improvement
Secondary Drivers
The number of fully trained
technicians available
•
•
•
•
The level of demand for the
service
45 Accurate ECHOS
are completed per
day (8:30 – 9:30)
- Cardio Clinic demand
- Other OPD demand
- Inpatient demand
•
•
Optimising available time
- Scheduling
•
•
•
Motivated staff
Effective leadership &
management
-
Work environment
Work load
Staff rotation
Recognition
- Effective Cardio team
meeting
- Visibility of variation
- Operations & change
management skills
- Clinical Leadership
•
•
•
•
•
•
•
•
The number of vacancies
The level of experience of
new recruits
The quality and pace of
training
Forecasting demand e.g.
25 to 35% of Cardio Clinic
patients require Echo
Ability to control
inappropriate demand
using agreed referral
criteria
Standardised Scheduling
practice
CVIS
Adequate notice to
inpatients
Porter availability to bring
inpatients to ECHO Dept
HCA to assist with patient
prep
Area to have lunch
Ability to take scheduled
breaks
Team working & support
from Consultant team
CVIS System
ECHO dashboard
Multidiscipline operations
management meeting
Continuous improvement
Vs Ad-hoc management
Scenario 1: Afternoon Cardio OPD Clinic
Actual Patient arrival times
Allocating these patients to nearest “25”minute scheduled slot
Conclusions:
•
Staff would have been able to take breaks
•
17 Slots would have remained unfilled – approx 50% of capacity
•
Only one Cardio patient would have had to wait for a significantly longer period outside the ECHO room
Actual number of ECHOs completed
5/8/14 - 25/8/14 (15 Days)
Potential output over same
period (15 days) If daily target
met
Sustainability
Su
nd
ay
M
on
da
Tu y
es
W
da
ed
y
ne
sd
Th ay
ur
sd
ay
Fr
id
Sa a y
tu
rd
ay
Su
nd
ay
M
on
da
Tu y
es
W
da
ed
y
ne
sd
Th ay
ur
sd
ay
Fr
id
Sa a y
tu
rd
ay
Su
nd
ay
M
on
da
Tu y
es
W
da
ed
y
ne
sd
Th ay
ur
sd
ay
Fr
id
Sa a y
tu
rd
ay
Su
nd
ay
M
on
da
Tu y
es
W
da
ed
y
ne
sd
Th ay
ur
sd
ay
Fr
id
Sa a y
tu
rd
ay
Su
nd
ay
M
on
da
Tu y
es
da
y
Y=
Individuals: Discharges
Module 1: Measuring variation (Y=f(X1.X2.X3.X4……..Xn)
50.00
47.63
40.00
30.00
20.00
Mean CL: 17.48
10.00
0.00
-10.00
-12.66
-20.00
Xn=
X1
X2
X3
X4
X5
X6
X7
X8
X9
X10
Electronic dashboard showing Y & X real time
Month Bar
Can be widened or narrowed
Time
axis
Actual Start time
8.30 Aim
Day of week
List of actual start times
Filter options:
By Speciality, Theatre or Day of week
Reasons for delay
Key Improvement tools
95%
5%
Data
analysis
Flow
analysis
Change
Management
Process mapping 410-411
Stakeholder Management (Chp 8)
Measuring Variation
Identifying waste
Communication planning (Chp 8)
Illustrating
•Run Charts (Chp 2 & 3))
•Pareto charts -436-437
Influencing styles
Process mapping symbols and steps
TRAINING PENSIONS PROCESS EXAMPLE
Post Team
Process mapping
symbols
Schedule
appointment
Describes each process step
(verb noun construction)
Is
ventilation
required?
Yes
No
Describes decision points
A
Used to link a process that
flows on to second page
2. Sort
Post
Processing
Team
Indicates the start point
(trigger) of a process &
the end point of a process
(final output)
1 Post received
Payments
Team
Receive
referral
Swim lanes –
one per role or
team. Used to
illustrate who
does which
step and where
the hand off
occurs
Process
title
3. Distribute
Post
Yes
4. Review
Form
5. Is all Info
present ?
No
6. Request
Information
7. Enter
Contribution
details
8. Is customer
eligible?
10. Set up
Payment
No
9. Send
Notification
11. Send
notification
of payment
A
12. Put away
claim
Process mapping steps
Identify the teams/roles involved in the process
(1)Draw a swim lane for each role/team
(2)Identify the start point (trigger) and end points
(3)Draw start and end symbols in the appropriate swim
lanes
(4)Identify the process steps and link them using arrows
(5)Discuss process issues / opportunities to improve
process as you create the map
(6)Document map and issues & validate with users
Process mapping – Key lessons
•
•
•
•
•
•
•
Do Observation 1st
Map the pathway through individual interview
Log issues as you go along
Hold a meeting to validate map & suggest improvements
Hold sub meetings to tease out detail design of each solution – using map to
“pedantically” facilitate the discussion
PDSA tests as you go – don’t do big bang implementation
Complete “to be” design map and convert to SOP
KEY point
• It’s the structured conversation you have while mapping rather than the map itself
is of vale.
• A map with out a log of issues and suggestions is of no value
• Mapping is an art not a science
Dementia Scheduled & unscheduled pathway
1.
carers in crisis have little
alternative to going to ED phone support
2. ED is not the appropriate place
to manage carers in crisis –
- rapid access crisis clinic
- carer Education programme
required
Dementia Scheduled & unscheduled pathway
1.
2.
3.
4.
5.
Difficult to identify quickly if
previous diagnosis of Dementia
exists. Community history of patient
is not available
- PAS system Flag
- Can MRN number be used to link
to Old Age Psych patient record?
- Introduce “this is me” form
No Triage Protocol for Confused/
Delirium patients - Agree Triage
Protocol
Assessment for Delirium/ Cognitive
impairment not part of standard
Triage/ED Assessment bundle –
single short test to be incorporated
in ED Assessment
No specifically designed assessment
Area - Identify and furnish
assessment area
Not all staff trained in management
and assessment of Confused
patients – nurses , HCAs, specials
etc – Design awareness training
Dementia Scheduled & unscheduled pathway
•
Doesn’t appear to be a
clear pathway for
previously diagnosed
Dementia patients who
are admitted
- agree pre diagnosed
dementia pathway
- Is a Dementia specific
team required/
Key Improvement tools
95%
5%
Data
analysis
Flow
analysis
Change
Management
Process mapping 410-411
Stakeholder Management (Chp 8)
Measuring Variation
Identifying waste
Communication planning (Chp 8)
Illustrating
•Run Charts (Chp 2 & 3))
•Pareto charts -436-437
Influencing styles
Why is Change Management important ?
Top 10 Success Factors
% of 500 organisations
Ensuring senior management
sponsorship
Treating people fairly
Involving staff
Giving quality communications
Providing sufficient training
Using clear performance measures
Building teams
Focusing on culture/skill changes
Rewarding success
Using internal champions
82%
82%
75%
70%
68%
65%
62%
62%
60%
60%
9 out of 10 change project success factors are people related
Source: iibm Mori Survey 1997
Flattening the change curve
Stakeholder Perceptions
+
-
High
Expectations
With effective
Implementation
Realisation of effort
and complexity
Better than
before
Light at the end
of the tunnel
Change
Implementation
Despair
—Unmanaged Change
—Managed Change
Influence mapping
Level of influence
H
i
g
h
M
e
d
i
u
m
L
o
w
Low
Medium
Support for change
High
Getting buy-in – Lisa’s project
Stakeholder
Initial
Level of
support influence
Key Concern
Steps to getting buy in
Pharmacy
H
H
Fear
Constant communication &
reassurance
Management
L
H
Other priorities
Communication & data;
ownership (made to feel part of
solution) – Its about money
CNS Staff
L
H
“Waste is not part
of our
responsibility”
Constant communication – Its
about safety
Patients
L
H
Extra visits
Communication and improved
service, improved care
Consultants
L
H
Unaware of data
and significance
Data
Transactional Analysis
Nurturing Parent – Provides support, non-judgemental
NP CP
acceptance, and assists in healthy growth
Critical Parent – Prescriptive, tells, obsessed with rules,
judgemental, authoritarian, discounting, divisive
A
Adult – Does clear thinking, questions, is assertive and generates
options to help with problem solving, planning, and productive
procedures
Innovative Child – Generates ideas, comes up with creative
IC
solutions, sees things from different perspectives, open minded, is
fun to be with, creates energy
RC
Rebellious Child – Doesn’t obey/follow rules and procedures.
SC
Rebels against any form of authority. They send I am OK, you are
not OK messages
Sulking Child – Submissive. Feels and acts like a victim. Sends
you are OK, I am not OK messages.
Agenda
Part 1: The benefits and limits of Top Down Change
Lessons learnt from establishing and managing the National Clinical Programmes
Part 2: Relearning how to use improvement tools in health care
Measurement: Hip Fracture Pathway & ECHO Utilisation
Mapping patient flow: Dementia Pathway
Influencing change: Chemo Drug Savings
Part 3: Observations on teaching clinicians QI
RCPI Diploma in Leadership & Quality
Part 4: Sustaining change
Building a Directorate Model that imbeds continuous improvement
Close: 5 years “Learning” on a page
Observations about training Clinicians in QI
•
Realising they needed a “babel fish” to understand what I was saying
– Keep language/ terminology simple
•
As a non clinician I was never going to get over the credibility gap
– Front training with Clinicians ( Train the Trainer training)
•
•
•
•
•
•
•
•
Expose them to what is possible by having speakers from other hospitals with a QI
culture e.g. Cincinnati Hospital
Use SCYPE so they can connect virtually to the class room
Coaching is key – training alone won’t build confidence – use Web meetings to
coach
Clinicians need time to absorb and adjust there mind set – Intensive sessions over
long period seems to work – it’s a form of therapy – the light goes on at different
timed for different people
Strong focus on leadership and self reflection – they need to vent and articulate
anger / frustration – but bring them back to believing they can make a difference
Mantra of making one difference to one patient – works – steer them away from
curing world hunger
Make change fun – it increases the chances of success – don’t be afraid to
encourage them to be creative
Back at base – regular lunch and learns seems to be better than class room courses
Understand the problem 1st choose the method second
Pathway/ Process maturity
Quality Safety & Capacity improvement
6 Disruptive
innovation
when capacity is optimised & change is required to meet
demand
High
High Reliability
5 Flow defect free
e.g. 6-sigma review
4 Reliable patient centred care
e.g. IHI – QI Method and Reliability theory
3 End to end Flow efficiency
e.g. Lean review
2 Flow standardised
e.g. documented SOP, guideline, algorithm, ICP.
1 Organisational Fundamentals are present
e.g. defined pathway objective, Metric(s), clear
accountability, scheduled performance review meeting,
(Micro Systems)
Low
High
Level of analysis
required