implementation / quality improvement some practical wisdom

Implementation / Quality

Improvement Some practical wisdom

Tim Stephens BA (Hons), MSc, RGN QI Specialist & Nurse Researcher

Critical Care and Perioperative Medicine Research Group, Queen Mary, University of London

Learning objectives

1.  Understand the development of the sciences of improvement & implementation

2.  Learn some key strategies for doing improvement at the frontline

3.  Learn some strategies for doing good, robust improvement research

1. Methods for improving quality and safety

Q & S in healthcare

Audit

QI

IS

Legal

Prof

Training

The Audit Cycle

Problem #1 with the audit cycle is that is a before and after study – so you can understand how the system may be at variance to the standards, but not the variation in the system

The Audit Cycle

Problem #2 with the audit cycle is that ‘implement change’ belies the often challenging and complex nature of improvement activities, and the need for specific change methods

Quality Improvement & Implementation Science

The science of QI

• Knowledge from industry •  Juran and Deming – Japanese car industry •  Promoted by the IHI since late 1990s •  Primarily process and system

improvement • More practical than academic • Underpinned by:

–  understanding variation –  using local expertise –  understanding the psychology of change –  an ethos of learning by doing

Donabedian's model of quality assessment

1.  Access to imaging

2.  Emergency theatre capacity

3.  On-call rotas

1.  Pathways 2.  Cons

delivered care

3.  Mortality risk scoring

4.  Time to theatre

5.  Critical care admission

1.  LOS 2.  Mortality

Quality Improvement

•  “Every system is perfectly designed to achieve the results that it gets; if you want to improve results then you have to change the system”

•  Paul Batalden, IHI

•  “If I was to say what was the one most important thing to improve quality, it is understanding and reducing variation…”

• Don Berwick, IHI

Variation and time

Variation and Time

Median

0

5

10

15

20

25

30

Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

% Overall 30 Day Mortality

Pathway Implemented

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in

improvement?

The Model for Improvement

Source:

Langley, et al. The Improvement Guide, 1996.

The three questions provide the

strategy

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do

Quality Improvement

•  Extension and improvement on audit cycle

• Generally (not always) continuous measures

•  Explicit change method – usually PDSA

Implementation Science

• Developed from the social and behavioural sciences

• Based upon theoretical frameworks – Diffusion of Innovation theory –  Theoretical Domains Framework – Consolidated Framework for Implementation

• More interested in influencing people • Attempts to embrace complexity •  Perhaps more academic than practical

Consolidated Framework for Implementation and ResearchDamschroder et al (2009)

Milbank QuarterlyVolume 82, Issue 4, pages 581-629, 9 DEC 2004 DOI: 10.1111/j.0887-378X.2004.00325.x http://onlinelibrary.wiley.com/doi/10.1111/j.0887-378X.2004.00325.x/full#f3

One definition of 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”

•  Øvretveit J. 2009 Does improving quality save money? A review of the evidence of which improvements to quality reduce costs to health service providers. London: Health Foundation,

All improvement has…

A ‘hard core’:

A ‘soft periphery’:

Context:

Langley A, Denis J Beyond evidence: the micropolitics of improvement Quality and Safety in Health Care 2011;20:i43-i46.


A ‘hard core’: Clinical intervention / process

A ‘soft periphery’: Strategy to get intervention into practice / improve process

Context: Team / organizational culture, pressures, leadership etc


Clinical intervention / process

Strategy to get intervention into practice / improve process

Culture, pressures, leadership etc

Audit, implementation of research findings and QI

Difference b/t QI and implementation

• QI – problem focussed •  Implementation – solution focussed • QI – both the hard core (the ‘what’) and

the soft periphery (‘the how’) are explored

•  IS – usually just the soft periphery (the ‘how’, because the ‘what’ is known)

Quality Improvement

•  How to get more EmLap patients to theatre in a timely manner? –  No one single correct way –  Different solutions will work in different contexts –  Understanding the local context vital to success

–  No evidence based solutions –  But...

• can learn from other centres experiences (whose ideas may or may not work for you)

• Generate and test ideas from your team

Implementation

•  Evidence based intervention(s) exist

•  In an ideal world, the solution would be in reliably delivered in a very similar way everywhere

•  Context is key to the implementation, but not to the clinical solution

2. Doing improvement

•  ‘Every system is perfectly designed to get the results it gets. The only way to get real change is to change the system. To do this you need ‘will, ideas and execution’.

ü  You must have the Will to make the system change ü  You must have Ideas about how you could change

things ü  You must have skills to make it happen: Execution.

Paul Batalden IHI 1984

1.  Convince people that there is a problem 2.  Convince people of the proposed solution 3.  Establish sound data / measurement systems 4.  Avoid over-ambition / ‘projectness’ 5.  Consider organisational context and capacity 6.  Overcome tribalism - ownership / shared goals 7.  Getting leadership right 8.  Incentivise participation/use ‘hard-edges’ carefully 9.  Sustainment - use team approach / embed practice 10. Be aware of side effects

Clinical vs improvement interventions

• Would you prescribe / give a patient a clinical intervention without a clear rationale for its: –  purpose? – mechanism of effect? –  predicted result?

• Yet we often ‘treat’ clinical systems with interventions with very little thought for if and how the intervention will work

Rationale: treating new onset hypertention in 60 yr old man

•  If: –  Amlodipine 5mg is trialled & –  BP and side effects monitored & –  Lifestyle advice given

•  Then: –  BP is physiologically lowered (calcium channel blockade) & –  Medication can be titrated according to effect & –  Lifestyle causes of hypertension may be reduced

•  So that: –  New onset hypertension can be safely treated

•  So that: –  Hypertension related organ dysfunction is prevented

Rationale / Theory of change If -‐ Relevant data are reviewed and fed back to teams regularly, &

-‐ Key professionals come together to form an improvement team, &

-‐ QI leads and colleagues learn basic quality improvement approaches, &

-‐ Relevant stakeholders are made aware of the project and improvement goals

Then

-‐ A shared view of performance and improvement gaps can be created , &

-‐ Professionals can work as a team to define and achieve local improvement goals, &

-‐ Basic quality improvement approaches can be employed to achieve the improvement goals, &

-‐ Stakeholders will be more engaged in the need for change and aware of how improvement will occur

So that

-‐ Improvements in care delivery in line with the recommended care pathway can be achieved

So that

-‐ Mortality aGer emergency laparotomy can be reduced.

Collaborative goals and drivers

Goal: Cholecystectomy within 8 days of

presentation (Measure: % eligible admitted patients having surgery ≤8

days)

Primary Driver 1: Reduce time to

diagnosis to within 24hrs from

presentation

2⁰ Driver 1: Timely imaging / diagnosis

2⁰ Driver 2: Timely decision making

Primary Driver 2: Reduce time to surgery To within 2 days from diagnosis (IP); 7 days

(OP)

2⁰ Driver 3: Clear pathway of care

2⁰ Driver 4: Surgical capacity

2⁰ Driver 5: Theatre capacity

2⁰ Driver 6: Support of theatre team &

management

The 7 Steps to QI Measurement

¢


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

improvement?


Act Plan

Study Do Source: Langley, et al. The Improvement Guide, 1996.

The three questions provide

the strategy

The PDSA cycle provides the

tactical approach to

work




improvement?


Source:



strategy

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do

Act Plan

Study Do




improvement?


Source:



strategy

¢



improvement?


Source: Langley, et al. The Improvement Guide, 1996.


the strategy

Some change methods

The ‘hard core’

The ‘soft periphery’

Your context!

Rationale

• Why do you think that this/these interventions will work to improve care in your context at this time?


Clinical intervention / process

Strategy to get intervention into practice / improve process

Culture, pressures, leadership etc

¢



improvement?


Source: Langley, et al. The Improvement Guide, 1996.


the strategy

3. Doing improvement research

• Tension between: –  doing improvement and –  studying improvement

•  Sometimes doing is all that is possible but

•  Studying & doing develops the science •  If planned right, studying can improve

doing

Guidance on QI reporting

RATIONALE / THEORY

• Frameworks, models, concepts, theories used

•  Ideas / assumptions that guided intervention development

• “Why do you think this intervention(s) will work in this setting at this point in

time?”

Tips for developing your rationale:

• Make sure all the problem(s) have been identified – ask all stakeholders

• Make sure you keep good records of this process, it will help you with context/methods writing

•  Develop explicit diagrams to outline why you are doing what you are doing – your Mum should be able to follow your reasoning

STUDY OF THE INTERVENTION

Assessment of: •  Impact of the intervention on the

systems and people • (Did it work?) • Whether or not the observed change was

likely a result of your intervention • (Did it work for the reasons you think it did?)

Tips for ‘studying the intervention’

•  Should be built into your work – not easily done afterward

• Check fidelity of your implementation/uptake –  Process measures

• Collect data on predicted effect modifiers –  e.g. colleague reaction to new practice / process

• Always be a little sceptical of your success: –  look for alternative explanations –  consider potential confounders

• Check for unintended effects –good and bad

CONTEXT

•  The setting in which the problem occurs and the work is done

•  Like “setting” in biomedical model - only much more

•  Called ‘thick description’ in social sciences •  ‘All the things that are not your

intervention’ •  Contextual elements that interacted with the

intervention(s) (All the things that made it succeed /

made it fail)

Summary

•  Improving quality ≠ Quality Improvement • Many different change methods •  RelaLvely limited evidence base currently •  Rapidly evolving area of applied health research

•  Use the 3 quesLons in the Model for Improvement and be clear why you are doing what you are doing!

Thank you

Tim Stephens

[email protected]

References

•  Perla, R.J., Provost, L.P. and Murray, S.K., 2011. The run chart: a simple analytical tool for learning from variation in healthcare processes. Quality and Safety in Health Care, 20(1), pp.46-51.

•  Dixon-Woods, M., McNicol, S. and Martin, G., 2012. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Qual Saf, pp.bmjqs-2011.

•  Goodman, D., Ogrinc, G., Davies, L., Baker, G.R., Barnsteiner, J., Foster, T.C., Gali, K., Hilden, J., Horwitz, L., Kaplan, H.C. and Leis, J., 2016. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V. 2.0: examples of SQUIRE elements in the healthcare improvement literature. BMJ Qual Saf, 25(12), pp.e7-e7.

•  Shouls, G., Jarrar, Z. and Wickenden, J., 2014. Improving phlebotomy handover to doctors: a quality improvement project. BMJ quality improvement reports, 3(1), pp.u204813-w2033.

Examples

•  Improving phlebotomy / FY Dr working •  ELPQUIC •  EPOCH

•  “Every system is perfectly designed to achieve the results that it gets; if you want to improve results then you have to change the system”

•  Paul Batalden, IHI

•  “If I was to say what was the one most important thing to improve quality, it is understanding and reducing variation…”

• Don Berwick, IHI

implementation / quality improvement some practical wisdom

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