Transcript Document

Local Quality Improvement – Successes and Failures
Katharine (Kat) Young MA
Senior Quality Improvement Lead, Royal Berkshire NHS FT
Chair, National Quality Improvement and Clinical Audit network
Member, National Advisory Group for Clinical Audit and Enquiries
[email protected]
@Clin_Q
www.hqip.org.uk
Royal Berkshire NHS Foundation Trust
• Large District General, Reading
• Strategic objectives:
– exceed patient and customer expectations
– work together to create a modern and sustainable healthcare
system
– deliver the best healthcare in the best possible place for
patients
– provide the best place to work, train and learn.
• Re-organisation 2011
• Move to three Care Groups (Urgent, Planned and Networked)
& Clinical Quality Improvement Unit
• Need to maximise clinical and financial efficiency
Where we were at
• Quality by name but not in nature
• The candy factory – I love Lucy
https://www.youtube.com/watch?v=8NPzLBSBzPI
• ‘Insanity: Doing the same thing over and over
again and expecting different results’
Albert Einstein/Benjamin Franklin/Anon
• Work harder?
Role of the Quality Improvement Team
• Champion and promote culture of continuous
improvement
• Leadership, expert advice
• Project support
• Building Capability and Capacity (facilitated
learning)
Working together to improve quality
RBFT Improve Framework
Quality Improvement Framework: Our journey towards excellence
Shared
Vision
SMART
Aims
The Quality
Improvement
Approach
Improve it!
The vision
should
answer the
question
‘where do
we want to
get to?’ and
should be
the
inspiration
and
framework
for planning
The aims set
should be:
Enable – provide
information and skills /
deliberate practice
Measure
Stakeholders – crucial
conversations – team and
beyond
Measurable
Plan
Achievable
RoI
Timeframe
Desirable – what’s in it for
them?
Improvement
opportunities
Specific
Realistic
Vital Behaviours
Outcomes
Vital
behaviours
Evaluate
Influencers – senior
engagement and support;
opinion leaders
Rewards – what are the
incentives?
Environment –providing the
physical means to achieve
the outcome
Governance Outcomes
Sustainability
Project
Management
Office (PMO)
involvement:
To sustain the
improvement
requires:
-Projects
grouped by
value (P1-P3)
-Tracking &
monitoring
-Project
documents
-Risk
assessments
-QIPP Reports Programme
Board
What are the
Process
measures?
What are the
Outcome
Measures?
-Patient & staff
engagement
-Alignment with
goals &
structures
-Infrastructure
-Credible
evidence
-Adaptability
-Continual
monitoring of
progress
Assurance
CQIU
involvement:
Involvement
in
completion
& challenge
of Quality
Impact
Assessments
- Monitoring
of balancing
measures
- Research
capability
Shared Learning, show casing of examples such as MEMC, clinical leadership programme etc
RBFT Quality Improvement Training Programme (training, master classes, visits to centres of excellence)
Communication Strategy –sharing plans, outcomes & celebrating success
RBFT The
Improve:
Approach
Quality Improvement
Approach: IMPROVE
Improvement Measure
Plan
RoI
Outcomes
Methodology
How…
opportunity
… do we
want to
improve?
…. do we
generate
ideas?
Vital
Evaluate
Behaviours
… good are
we and how
do we know?
… do we
make the
changes?
… do we
prioritise?
… do we
demonstrate
it’s worth it
…are things
different
from before?
… will our
behaviours
support the
change
…timescale?
Brainstorm
RAG Study
Pareto
P&L
Benchmark
Process Map
Audit
Model for
Improvement
Historical
analysis
Staff
+Patient
Engagement
Spaghetti
Diagram
Baselines
PDSA
Lean
PMO Docs
5 D’s
Project Plan
Human /
Financial cost
and saving
SPC
Business
Cases
Owners
Timescales
Rapid
Improvemen
t Events
Six Sigma
Open to
change
See the
benefit or
bigger
picture
Engagement
… will we
know we
have made a
difference,
and how do
we keep
improving?
Review
performance
Communicate
change
Ensure
sustainability
Celebrate
Success
Doing things differently
•
•
•
•
•
•
Clinical Leadership
Board/Executive support
Reducing bureaucracy
Interaction / workshops
Staff and patient involvement – all levels
Facilitated learning
Behavioural change
• Vision – they why
• What do you need
to make it
happen?
• How?
• DESIRABLE
•
•
•
•
•
ENABLE
STAKEHOLDERS
INFLUENCE
REWARDS
ENVIRONMENT
What’s in it for
them
Provide info / skills
Team & beyond
Supervisor / Seniors
Incentives
e.g. checklist, rota
Patient Leaders
• Recruitment based on values (12
to date)
• 7 day modular Patient Leader
programme includes QI
• Supporting/leading Quality
Improvement projects – working
in collaboration
Quality Improvement Methodology
•
•
•
•
•
•
•
Root Cause Analysis
Pareto
Driver diagrams
Importance of measurement: run charts
Model for Improvement / Clinical Audit
Process Mapping
Lean / Six Sigma
A model for learning and change
When you
combine
the 3
questions
with the…
PDSA cycle,
you get…
…the Model for
Improvement
WHY are
We doing it?
HOW we
will do it
12
Move away from traditional clinical audit
Move from traditional audit cycles to real-time, dynamic improvement change audit
Importance of Measurement: Use of run charts
The change seems to
be associated with an
improvement
The change is not associated with an
improvement; if there had been no
baseline measurement before
making the change, the change
mioght have been mistakenly
interpreted as making a difference
The change seems to be associated
with an improvement initially but the
effect does not appear sustained
Remember measure little
and often
Perla R. BMJ Qual Saf 2011; 20: 46-51
What are we doing differently: Structure
Trust Clinical
Governance
Clinical
Outcomes &
Effectiveness
group
Quality
Performance
Committee
Care Group
Clinical
Governance
Specialty
Clinical
Governance
NED: Janet Rutherford
DQORG =
Data Quality
Outcomes
Review
Group
What are we doing differently?
• Training/learning - basic
• Model for improvement
• Rapid audit cycles/PDSA
• Importance of measurement
/ run charts
• Driver diagrams
• 1:1 Coaching/support
• Value of personal interaction
What are we doing differently?
SMART
Aims
Outcome
focussed
What are we doing differently?
Primary Drivers
AIM: Increase
number of EDLs
completed
within 24 hours
of discharge to
70% within 3
months on
ward B to
enable effective
discharge
planning
Discharge
decision
EDL write up
Pharmacy
Content
Secondary Drivers
•Ward round times
•Ward round structure
•Consultant-led decision making
•Elective admission- predictable
•Emergency admission
•Junior doctor availability
•Opportunities for completion
•Time needed for completion
•TTO completion
•Opening times
•Ward pharmacist
•portering
•Information to GP
•Mandatory
•format
•coding
Topic
selection
Successes: improvement in outcomes / sustainability
IMPROVE: Hospital Acquired Pneumonia
Week (starting October 2013)
Successes: improvement in outcomes / sustainability
IMPROVE: Hospital Acquired Pneumonia
Bed heads raised to 30
degrees at week 9 (17Dec)
18
Oral hygiene
measures Victoria
Ward week 25 (8Apr) Oral hygiene
16
14
Trust w ide roll out
w eek 43 (12 Aug)
measures across 8
wards week 29
(6May)
12
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Week
Total on 8 wards
2012 Prevalence audits on 4 wards
5
4
3
2
1
0
1
2
3
4
2013 HAP prevalence 8 wards
10
9
8
7
6
5
4
3
2
1
0
1
2
3
4
5
Mean
10
9
8
7
6
5
4
3
2
1
0
Number of patients with HAP
Number of patients with HAP
HAP on 8 wards
HAP on 8 wards - progress chart
HAP prevention
measures re- launched
0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435363738394041424344
6
Week
Week (starting October 2013)
Successes: rapid improvements
Trainees experience
“It was very useful, and its good to know
that you can really make a difference - I
am now more aware of what we can do,
and how to take action.”
“My supervisor was very supportive and motivating throughout…I
would definitely do a QIP again.”
Ram Jeeneea CT1
Faraz Siddiqui FY1
“For the patient a QIP means an
improvement in the quality of service they
receive from the simplest of things to
more complex issues all with the intention
of improving patient experience and
quality of life.” Anna Brown, CMT1
“I am definitely empowered, and now have the
understanding that I can make changes.”
Kunal Kulkarni FY1
“This has been a very valuable learning
experience into clinical quality
improvement as well as being brilliant for
my CV. The MEMC team have been
supportive and encouraging throughout
and there has always been someone
available to talk to if I have ever needed
any help.” Anna Weil, FY2
“The DVD produced as part of “Making Every Moment Count” will make an enormous
difference to patients on the run up to their surgery, it will ease fears before surgery and
calm nerves on the day of surgery”. Olivia Johnson, a patient involved in MEMC
“You hear about projects and they
sound really huge, but this has
opened my eyes to how you can do
little things and make small changes
that make a big difference.”
Anna Roche FY2
“Overall it is very satisfying to engage with
trainees and to supervise a QIP as they have
an enthusiasm and motivation which is a
real joy to work with. I very much enjoyed
supervising a QIP project this year”. Maeve
McKeogh, Consultant Supervisor
Successes: changing culture
Feedback 1 year on
Lessons learnt
•
•
•
•
Need to change culture / mindsets
Make it personal
Lots of QI Methods: learning needs
Traditional clinical audit switches a lot of people off
• Use standards where they exist, you can make
improvements without them
• Need greater focus on outcomes / return on
investment at start of process
• Staff including Junior Doctors and Patient Leaders
are real assets
Future
• Roll out Making Every Moment Count (junior
doctor) programme to all Trust staff
• Continue focus on outcomes
• Increase ability to assess Return on Investment
• Sustainability
• Increase facilitated learning
• Share our learning
Scenarios
Scenarios
What do you need to do more of / less of?
CULTURE
• In relation to clinical audit / quality improvement what is the
culture in my organisation?
• What behaviours need to change? How to change?
• Are we are learning organisation?
• Do we have meaningful patient engagement/involvement?
STRUCTURE
• Where is quality compromised by silo working?
• Who are your clinical leaders?
• How engaged are your Board/Executive?
• How are we hearing the patient’s voice?
Scenarios
PROCESS
• Is process geared around your customers/staff or the
clinical audit team?
• Are people put off by your registration process?
• How accessible is the clinical audit / QI team?
OUTCOMES
• Are outcomes measured / shared?
• Is the impact of intervention on outcome known?
• Is return on investment known/ shared?
Resources
Learning to make a difference : Making Every Moment Count
PIlot
• https://www.youtube.com/watch?v=brZv_tftn_M
• http://www.clinmed.rcpjournal.org/content/12/6/520.full
• https://www.rcplondon.ac.uk/projects/learning-makedifference-ltmd
• https://www.youtube.com/watch?v=sNKXOEPIe2Q&featur
e=youtu.be