A Taste of Quality Improvement - Workbook Dean Rigg - Care City Quality Improvement Lead [email protected] 19th October 2016

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Open access. Some rights reserved. One of the key aims of Care City is to increase resilience across the system’s workforce by inspiring new entrants, facilitating life-long learning and generating future leaders. As such, we want to encourage the circulation of our work as widely as possible, while retaining the copyright. We therefore have an open access policy, which enables anyone to access our content online without charge. Anyone can download, save, perform or distribute this work in any format, without written permission. This work is therefore licensed under a Creative Commons Attribution - Non Commercial 4.0 International License. You are free to: Share – copy and redistribute the work in any medium or format Adapt – transform and build upon the material Under the following terms: Attribution – You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests that Care City endorses you or your use. Non-commercial – You may not use the material for commercial purposes. No additional restrictions – You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. Notices: You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation. No warranties are given. The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material. Please click here for more information.

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Agenda Welcome and scene setting Session 1 – What is Quality? Session 2 – A Brief History of Improvement Science Break Session 3 - Identifying the Change Needed Session 4 – Planning Your Test of Change Session 5 – ‘Do’ – Testing Your Change Ideas Session 6 – ‘Study’ Your Test of Change Session 7 - ‘Act’ Upon the Study Phase Session 8 – Plenary

Aim & Objectives Aim of the session: To empower you to participate in quality improvement initiatives, by providing you with an introduction to quality improvement methodologies. Objectives – by the end of the session you will be able to:  Define quality in health and social care  Explain why we need to make improvements  Summarise the history of improvement science  Analyse your own area of practice using the system of profound knowledge  Adopt the model for improvement in change initiatives  Process data for the purpose of quality improvement.

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An Introduction to Quality Improvement Slide 1

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An Introduction to Quality Improvement

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Slide 2

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Aim & Objectives Aim of the day: To empower you to participate in quality improvement initiatives, by providing you with an introduction to quality improvement methodologies. Objectives – by the end of the day you will be able to:  Define quality in health and social care  Explain why we need to make improvements  Summarise the history of improvement science  Analyse your own area of practice using the system of profound knowledge  Adopt the model for improvement in change initiatives  Process data for the purpose of quality improvement .

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Slide 3

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Session 1 – What is Quality? Slide 4

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Session 1: What is Quality?

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Slide 5

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What does Deming say?

___________________________________ “Quality is meeting and exceeding the customer’s needs and expectations and then continuing to improve.” W. Edwards Deming

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Slide 6

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The STEEEP Slope to Quality Providing care that is respectful of and Providing services Providing care that responsive to based on scientific Reducing waits does not vary in individual service Avoiding waste, knowledge to all and sometimes quality because ofuser preferences, including waste whoneeds could and benefit. harmful delays values. personal for both thoseof equipment, Avoiding injuries characteristics. supplies, ideas who receive and to service users and energy. from the carethose who give Person care. that is intended to help them. Effective Centred

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Equitable Efficient Timely Safe

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Slide 7

Why Change?

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Slide 8

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“The NHS is on the Hook…”

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Slide 9

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What is Quality Improvement?

___________________________________ “The conception of improvement finally reached as a result of the review was to define improvement as better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies.”

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Slide 10

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Why Quality Improvement?

Quality Improvement Quality Assurance • • • •

Reactive Regulatory Retrospective Punitive

• • • • • •

Accreditation Systems Processes Imagination Prospective Personcentred

Continuous Quality Improvement • Information driven • Outcomes oriented • Innovative • Best practice • Sustainable • Consumer focus

Quality Improvement Maturity

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• Senior leadership • Community health • Improved outcomes • Safety culture • Exceed benchmarks

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Session 2 – A Brief History of Improvement Science Slide 11

Session 2: A Brief History of Improvement Science

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Slide 12

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The Improvement Science Players

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W. Edwards Deming 1900-1993

Walter A. Shewhart 1891-1967

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Slide 13

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A Timeline of Improvement 1918 Shewhart joins inspection Engineering Dept. of Western Electric. Begins to rethink quality control.

1931

1950s

Shewhart publishes ‘Economic Control of Quality of Manufacturing’ – we enter a modern era of quality improvement.

Deming takes a modified version of the Shewhart Cycle to Japanse industry after WWII. Later evolves to the PDSA cycle.

1993 Deming publishes ‘The new Economics’ detailling PDSA and his ‘System of Profound Knowledge.

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1939 1925-1926 Deming meets Shewhart and becomes interested in his work.

Deming edits and Shewhart publishes ‘Statistical Mehod from the viewpoint of Quality Control’ – including the Shewhart Cycle.

1982

1994

Deming publishes ‘Out of the Crisis’ – offering management theory, based on 14 points of management.

Associates in process improvement add three questions to the PDSA cycle to form, ‘The Model for Imprveent’.

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Slide 14

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The Model for Improvement What are we trying to accomplish?

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How will we know that a change is an improvement? What change can we make that will result in improvement?

Act

Plan

Study

Do

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Session 3 – Identifying the Change Needed Slide 15

Session 3: Identifying the Change Needed

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Slide 16

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Lens of Profound Knowledge

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Appreciation of a System

___________________________________ Theory of Knowledge

Psychology

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Knowledge of Variation

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Slide 17

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Viewing Systems and Processes Ambulance crew arrives at ED.

Patient moved to triage area.

Ambulance clinician books patient in at reception.

Handover to doctor.

Pre-triage by nurse to screen for high acuity.

Ambulance clinician returns to triage area for handover.

Resus, majors or minors?

Ambulance clinicians move patient to clinical area.

Patient transfer to trolley.

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8 Forms of Waste in Health and Social Care What is Waste? Waste is any step or action in a process that is not required to complete that process successfully. These steps are referred to as non-value adding. When waste is removed, only the steps that are required to deliver a satisfactory service remain. These steps in the process are referred to as value-adding. Broadly speaking non-value adding steps fall under one of eight categories Defects This includes all time spent doing something incorrectly and inspecting or fixing errors. One example of defect waste is the time spent looking for a missing item or time spent investigating an incident.

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Over-production This includes doing more than is needed by the service user or by doing it sooner than is needed. An example of this might be carrying out unnecessary tests or procedures or completing paperwork that is not pertinent to that service user. Waiting Waiting for the next event to occur or the next work activity can eat up time and resources. Service users waiting for an appointment is a sign of waste, as is employees waiting because their workloads are not level. Non-Utilised Talent This waste is caused when employees are not engaged, heard or supported or when employees are not able to use the skills that they have. Employees that are not engaged will stop sharing their ideas for improvements. An example of non-utilised talent would be an employee with a set of skills that are scarce, completing the work that another colleague could complete.

Transportation Unnecessarily service users, specimens or equipment throughout a system is wasteful. This type of waste is evident when the physical environment in a system has a poor layout. For example, emergency surgery a long distance from the emergency department or community teams visiting service users in an order that incurs greater travel time. Inventory Waste can be created in health and social care when organisations incur excess inventory costs, storage and movement costs, spoilage and waste. One example is letting supplies expire and then disposing of them, including out of data medicines. Motion Do employees move from room to room, floor to floor and building to building more than is necessary? That may account for one type of waste. For example, lab employees may walk miles per day due to a poor hospital layout. Over-processing This describes work performed that is not valued by the service user or caused by definitions of quality that aren’t aligned with the service user’s needs. An example of this might include the patient history being taken multiple times by multiple professionals.

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Slide 19

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Psychology

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Barriers The expected autonomy of care workers

Stability that comes with routine Programmed behaviour or behaviours that result form processes within a system

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A limited focus or tunnel vision A real or perceived limit on resources An accumulation of policies, procedures and regulations.

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Slide 20

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Understanding Variation

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Slide 22

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Theory of Knowledge

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What are we trying to accomplish? How will we know that a change is an improvement?

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What change can we make that will result in improvement?

Act

Plan

Study

Do

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Slide 23

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Using the Model for Improvement

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What are we trying to accomplish?

How will we know that a change is an improvement?

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What change can we make that will result in improvement?

Act

Plan

Act

Plan

Study

Do

Study

Do

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Slide 24

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Setting an Aim

___________________________________ ___________________________________ ___________________________________ “Reduce the“To number take 95% of service “To of ambulance ensure 85% “All crew of new service referrals users to clinic must users who wait handovers longer than within attend 15 10their minutes own have of MDT an appointment by March within 2 minutes for their their appointment.” arrival by January 2017.” 2017.”weeks of referral.”

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

My SMART aim statement:

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Why Measure?

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Slide 28

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Displaying Data Over Time Time to Handover in the ED

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1000

900

800

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Intervention 1 Time to Handover (seconds)

700

Baseline Median

600

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Goal

500

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Day

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Slide 29

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Creating Exciting Change Ideas Increase calories burned To reach 20% body fat by January 2017.

Increase aerobic exercise

___________________________________ CrossFit

Increase muscle mass

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Eliminate sugar

Reduce calorie input

Make Substitutions

Reduce carbohydrates Meal Prep Reduce fatty foods

Committed attitude & behaviour

Gain peer support

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My Fitness Pal Awareness of habits Monitor progress

Support Group

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Your Driver Diagram

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Planning Your Test of Change Slide 30

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Session 4: Planning Your Test of Change

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Slide 32

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Planning

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State the objective of the test.

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State the questions you want to answer, and make predictions.

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Develop a plan to test the change. (Who? What? When? Where? What data?

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Slide 33

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Planning for Data Collection • What information is important to collect?

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• Why is it important?

• Who will collect the data?

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• Who will analyse the data prior to ‘Study’? • Where will the data be collected?

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• When will data collection take place? • How will the data (measures or observations) be

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collected?

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Slide 34

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Sampling for Quality Improvement

Simple Random Sampling

• Random data sampling from a population • Random selection process – e.g. computer or number table.

Stratified Random Sampling

• Dividing population into categories and taking a random sample from each category • Take a proportional amount from each category, depending on group size.

Judgement Sampling

• Relies on judgement of people with knowledge of system you’re trying to improve • People with expertise intentionally select useful samples.

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Session 5 – ‘Do’ - Testing Your Change Ideas Slide 35

Session 5: ‘Do’ – Testing Your Change Ideas

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Slide 36

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Testing Change Ideas

 What happens as testers try to accomplish the task or

tasks?

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 What seems hard or awkward?  What steps get skipped or altered?

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 What are the unexpected consequences?  Any measurements you said you’d take.

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Slide 37

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Some Useful Tips  Avoid over analysis. Begin testing as quickly as possible.

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 Start small. For the first test, start with one intervention,

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with one care provider and one service user.  Remember that PDSA cycles are for learning and your

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first test isn’t supposed to be perfect!  A test that fails is sometimes more useful for learning than a successful test.

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Slide 38

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Tennis Ball Game 5 People:

1

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3

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1

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6 People:

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7 People:

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8 People:

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1

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Slide 39

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Test Some Changes!

___________________________________ Aim Statement: We will reduce the time taken for every person to touch the ball in sequence by at least 50% after the next 3 cycles of the process.

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Rules: • The initial sequence must be adhered to • You may only test one change idea at a time • Record the time and ball drops after each change.

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The Tennis Ball Game

Process Cycle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Cycle Time (seconds) 15 14 15 12

Ball Drops

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Session 6 – ‘Study’ Your Test of Change Slide 40

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Session 6 – ‘Study’ Your Test of Change

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Slide 41

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Studying Your Test

___________________________________ The debriefing part of PDSA

Compare the data to your predictions

Complete your data analysis

Summarise and reflect on your learning.

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Slide 52

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Create Your Own Run Chart Time to Handover in the ED

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1000

900

800

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Intervention 1 Time to Handover (seconds)

700

Baseline Median

600

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Goal

500

400 1

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Day

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Section 7 – ‘Act’ Upon the Study Phase Slide 53

Session 7: ‘Act’ Upon the Study Phase

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Slide 54

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Acting on Your Study

Think Ahead!

Start Small!

Get Started!

Adopt, Adapt or Discard!

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Session 8: Plenary Slide 55

Session 8: Plenary

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Slide 56

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Other Resources

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Slide 57

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The Life System

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Slide 58

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Aim & Objectives Aim of the day: To empower you to participate in quality improvement initiatives, by providing you with an introduction to quality improvement methodologies. Objectives – by the end of the day you will be able to:  Define quality in health and social care  Explain why we need to make improvements  Summarise the history of improvement science  Analyse your own area of practice using the system of profound knowledge  Adopt the model for improvement in change initiatives  Process data for the purpose of quality improvement .

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

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