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11/29/2016

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HIGH FIVEPeople at the Centre of Improvement

The Five Essentials of Quality Improvement Dr Pat OConnor

Scottish Ambulance Service

Dr Peter Lachman

CEO, The International Society for Quality in Health Care

L5

Sunday, December 4

Key outcomes of today

• Have fun

• Discuss are people at the centre of your healthcare systems…. patients and families and healthcare teams

• Sharing and learning build on what we have

• Your box to go (take away tools) share and exchange

• Make a plan to at least try one new thing you learned

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Key content of The High Five

Improving Access Improving Care Improving Outcomes

• Is everything ....islands of excellence

• Where are the bright spots and how do we build on these?

• Strong and loose ties

Context

• Understanding self and others-Team dynamic

• Mindfulness, emotional intelligence: FEELINGS matter at work

• Make the right thing easy to try, easy to do and easy to try!

Making Change Happen

• Improvement science e.g. Model for improvement, lean

• Triple aim (patient experience, ROI, improved clinical outcomes)

• Community asset management

Methods tools and

techniques

•Measurement MATTERS

•Generate light not heat! Measures for improvement

•Dash board of measures- Run and control charts

•Info graphics

Measuring Results

• Deep and broad understanding of what it takes to sustain

change... reliability and resilience in care delivery ..Sensitive to

operations (Safety II )

• Acknowledge and monitor spread

• Celebrate Success

Holding the Gains

O’Connor 2015, Unpublished

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People at the Center

Are people at the center of your

service? ….Staff Patients and carers

Lets hear some examples:

Chat to your neighbour

share the ways you think

people are at the centre

of your care system

Changing from

What’s the matter?

To

What matters to you?

• Asking what matters

• Listening to what matters

• Doing what matters

We challenge you to ask the next patient you

care for, ‘what matters to you?’

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What matters to you video

https://www.youtube.com/watch?v=T-SkAb52f58

Jennifer Rogers on what matters to you

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Ask patients and colleagues

Finish the sentence

“…Today would have been better if….”

The 4 principles of person centred care

http://www.health.org.uk/public/cms/75/76/313/4772/Measuring%20what%20really%20matters.pdf?realName=GuxZKx.pdf

Dignity respect

compassion

Coordinated

Personalised

Enabling

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What makes the best care experience?

What makes the best

service?

Discuss with your neighbor

what is the best service you

have every had outside

healthcare and why?

People at the centre

Good example you heard

Something you need help with

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1 Context

• Is everything ....islands of excellence

• Where are the bright spots and how do

we build on these?

• Strong and loose ties

Professor Paul Bate

Islands of Excellence

• Islands of Excellence in a Sea of Mediocrity

• We are good at everything …….just not

everywhere

• Good examples of improvement …how are

they mapped how do you know?

• Reaching out and encouraging others to reach

in

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Looking for the bright spots

Dan Heath

https://www.youtube.com/watch?v=zbLNOS7MxFc

Strong and loose tiesHelen Bevan

• In health and care, most change happens through “strong ties”.

• We are influenced to change by “people like us”, with the same background, interests and experiences as us; change is spread peer-to-peer.

• Yet the best opportunities for breakthrough, radical change comes when we also operate through “weak ties”, connecting with people who aren’t in our usual peer group who bring fresh ideas, influences and perspectives.

http://theedge.nhsiq.nhs.uk/the-strength-of-weak-ties/

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Context considerations for change

Context

For quality improvement to flourish it must be

carefully cultivated in a rich soil bed (a receptive

organisation), given constant attention

(sustained leadership), assured of appropriate

amounts

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Bate 2014

8 factors of receptive contexts for change

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Context within which you work

In your organization what is

helping you to improve and what

is holding you back?

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2 Making Change Happen

• Understanding self and others-

• Team dynamic

• Mindfulness

• Emotional intelligence

• FEELINGS matter at work

• Make the right thing easy to

try, easy to do and easy to try!

AIM

Is there an agreed aim that

is understood by every one

in the system?

CORRECT

CHANGESAre we using our full

knowledge to identify the

right changes and

prioritising those likely to

have the biggest impact on

our AIM?

CHANGE

CLEAR

CHANGE

METHODDoes everyone know and

understand the method(S)

we will use to improve?

MEASUREMENT

Can we measure and report

progress on our

improvement aim?

CAPACITY

AND

CAPABILITY Are people and other

resources being deployed

and developed in the best

way to enable

improvement?

SCALE UP

AND SPREADHave we set out our plans

to test implement and scale

up, innovate and share

new learning to spread

improvement everywhere

its needed?

SIX Fundamental questions we must ask of all changes we

are trying to make

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The Science of Influence

https://www.youtube.com/watch?v=cFdCzN7RYbw

Where are you trying to

change practice ?

• When you see results somewhere else and

try it in your area is it working?

• Again share at your table

– when you have been successful in

improvement what did you do?

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Influence

To achieving balance and demonstrating understanding of the needs that underpin the position of the other

So you feel…

Tell me more…

I understand how you feel…

What can we/you do…?

27

The Five Conflict-Handling Modes

Asse

rtiv

en

ess

Cooperativeness

Ass

ert

ive

Unass

ert

ive

Uncooperative Cooperative

Competing Collaborating

Avoiding Accommodating

Compromising

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The Urban Monk

https://theurbanmonk.com/resources/ch5/

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Conflict

• Competing – assertive and uncooperative, a power

oriented mode. Self-interest.

• Collaborating – both assertive and cooperative. Work

with others.

• Compromising – intermediate in both assertiveness and

cooperativeness. Finding mutually agreeable solutions.

• Avoiding is unassertive and uncooperative. Steer clear of

the issue!

• Accommodating – unassertive and cooperative. Neglects

own interests to satisfy the other.

Habits of Improvers

http://www.health.org.uk/pu

blication/habits-improver

The Health Foundation 2015

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Making change happen

What tools do you use

share with your neighbour

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Making change happen…or not

• Singular piecemeal efforts will not work

• Education alone will not change behaviour

• Measurement is not change

• Exhortation and incentivisation alone work only if you believe that poor motivation is the root cause of the problem

If you want different results,

change the system !

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Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

Roger’s Adopter Categories

Change the world

Create the conditions

Make the improvement

Macro system

Set Vision, aim and context.

Meso system

Capability, Challenge.

Measurement

Culture

Micro system

Implementation,

measurement and

improvement

Three step Improvement Challenge

Adapted from IHI

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Kotter’s Change theory

Kotter 1990

Methods tools and techniques

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Break 2.30pm -3.00pm

3 Methods, tools and techniques

• Improvement science

• Model for improvement,

• Lean process mapping

• Triple aim

• Community asset

management

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Reference Donabedian

Structure Process Outcome

Quality Improvement in healthcare

https://www.youtube.com/watch?v=jq52ZjMzqyI

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Deming

• Beliefs

• Assumptions

• Motivation

• Interaction

• Learning from theory

and experience

• Prediction

• MFI

• PDSA

• To be expected

• Common and special cause

• Tampering

• Capability

• Interaction

• Optimisation

• Sub systems

• Micro system theory

Systems Variation

Psychology Theory of

knowledge

Profound or Improvement Knowledge

Knowledge for Improvement

Profound Knowledge

Subject Matter Knowledge

Improvement

Learn to combine subject matter

knowledge and profound

knowledge in creative ways to

develop effective changes for

improvement.

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By what method

Langley GL, Moen R, Nolan KM, Nolan

TW, Norman CL, Provost LP. The

Improvement Guide: A Practical Approach

to Enhancing Organizational

Performance (2nd edition). San Francisco:

Jossey-Bass Publishers; 2009.

Plan• Objective

• Questions &

predictions

• Plan to carry out:

Who?When?

How? Where?

Do• Carry out plan

• Document

problems

• Begin data

analysis

Act• Ready to

implement?

• Try something

else?

• Next cycle

Study• Complete data

analysis

• Compare to

predictions

• Summarize

What will happen if we

try something different?

Did it work?

What’s next?

The PDSA

Cycle

Do It !!!

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The test was planned (including a plan for

collecting data).

The plan was attempted (do the plan). (Make a

prediction)

Time was set aside to analyze the data and study

the results.

Action was rationally based on what was learned.

Source: Improvement Guide pp..60-61

TO BE CONSIDERED A PDSA CYCLE…

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IHI Triple Aim

Better

experience

Better

health

Great Staff

experience

Lower cost

The Quadruple Aim

Reference IHI

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Focus on your assets

Needs Assets

• Focus on deficiencies • Focus on strengths

• Result in fragmentation of

responses to local deficiencies

• Build relationships among people,

groups, and organizations

• Make people consumers of

services; builds dependence on

services

• Identify ways that people and

organizations give of their talents and

resources

• Give residents little voice in

deciding how to address local

concerns

• Empower people to be an integral part

of the solution to community problems

and issues

Focus on what you have

Create the beginnings of an asset

map

At your table record 3 things that are

contributing to improvement share

with your neighbor

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Values to Action

Inertia

Apathy

Fear

Self-doubt

Isolation

Urgency

Anger

Hope

You can make

a difference

Inclusion

Action inhibitors Action motivators

Ov

erc

om

e

Us a

s cha

ng

e le

ad

ers


Measuring Results

• Measurement MATTERS

• Generate light not heat!

• Measures for improvement

• Dash board of measures

• Run and control charts

• Info graphics

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Measuring Results

160

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LO

S (

min

ute

s)

Goal

Work-up done on floor

Bed ahead

Individual responsiblefor bed control

Quick-look x-rays

2/16/98 3/16 4/13 5/11 6/8

Week

Minimum Standard for Reporting Data in a

QI Project: Annotated Time Series

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15 Diabetes

Clinic teams

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J-07 F-07 M-07 A-07 M-07 J-07 J-07 A-07 S-07 O-07 N-07 D-07 J-08 F-08 M-08 A-08 M-08 J-08 J-08

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Scales for

Small Multiple

Graphs

2730

34

45 45 46 47 4743

47 48 48 4843 42 44

4 4 510 12 11 12 13 13 12 12 12 13 13 13 14

8

0

20

40

60

80

100


% of Patients with HbA1c <7- Aggregate of Diabetes Teams

Collaborative Data Analysis –

Small Multiples to Support Aggregate Displays

Out of Hospital Cardiac Arrest Programme� 10% increase in ROSC across Scotland� Co-Responding test with Scottish Fire & Rescue Service evaluation by Xmas ’16� Secured Health Foundation investment for remote and rural trial� Wildcat programme commenced� 138 CFRS (1500+ volunteers)� Co-hosted first European Resuscitation Academy to be held in the UK (June ‘16)� Pilot Co-responding with Police Scotland in Grampian for cardiac arrests

Clinical Services Transformation

0%

10%

20%

30%

40%

50%

60%

70%

80%

Return of Spontaneous Circulation for VF/VT patients

VF/VT ROSC Control Line (Pbar) UCL LCL Upper 3rd Lower 3rd Aim

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61

Hear and TreatRecruitment of additional clinical advisors and supervisors to establish clinical services hub

GP support to enhance triage and response for GP urgent requests

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

Ap

r-16

Ma

y-1

6

Jun

-16

Jul-1

6

Au

g-1

6

Se

p-1

6

Oct-1

6

No

v-1

6

De

c-16

Jan

-17

Fe

b-1

7

Ma

r-17

Hear & Treat Trajectory

Forecast Monthly % Hear & Treat Trajectory Hear & Treat Target


Patient Pathways � Active and Independent Living Improvement Programme (AILIP) established, SAS key member

� Collaborative event on 25th November - 24 IJBs have joined collaborative to date

� All divisions have Senior Divisional lead and a core group of local leads to work with partners on

developing, establishing and improving local pathways (priorities: falls, respiratory, mental health).

� Falls & Frailty page on the new ePR due for release next year

� Enabling more robust data collection for falls and frailty patients

� Potential to move to electronic referrals from the Service to Falls Teams


60.0%

62.0%

64.0%

66.0%

68.0%

70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Apr-15 Jun-15 Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17

Emergency Conveyence Rates

Emergency Conveyance %

Frail Elderly Conveyance %

Median: 73.5%

Median: 64.8%

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Measurement for Improvement

3 types of measures– outcome, process and balancing

Pragmatic Actions:• Tests Observable• Bias Stabilised• Just Enough Data• Adapts with Change• Rapid Cycle Change Sequential Tests• Run or Control Charts

The Three Faces of Performance Measurement

Aspect Improvement Accountability Research

Aim Improvement of care Comparison, choice, reassurance, spur for

change

New knowledge

Methods:

• Test Observability

Test is observable No test, evaluate current performance

Test blinded or controlled

• Bias Accept consistent bias Measure and adjust to reduce bias

Design to eliminate bias

• Sample Size “Just enough” data, small sequential samples

Obtain 100% of available, relevant data

“Just in case” data

• Flexibility of

Hypothesis

Hypothesis flexible, changes as learning takes

place

No hypothesis Fixed hypothesis

• Testing Strategy Sequential tests No tests One large test

• Determining if aChange is anImprovement

Run charts or Shewhart control charts

No change focus Hypothesis, statistical tests (t-test, F-test, chi

square), p-values

• Confidentiality ofthe Data

Data used only by those involved with improvement

Data available for public consumption and review

Research subjects’identities protected

“

““

“

The Three Faces of Performance Measurement: Improvement, Accountability and Research”””

”

Lief Solberg, Gordon Mosser and Sharon McDonald Journal on Quality Improvement vol. 23, no. 3, (March 1997), 135-147.

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http://www.qihub.scot.nhs.uk/improvement-journey/introduce/how-do-we-refine-the-

measurement-plan.aspx

BELIEF

Low degree

of belief

that change

idea will lead

to

improvement

High degree

of belief

that change

idea will lead

to

improvement

Current commitment within organisation

No

commitment

Some

commitment

Strong

commitment

COST OF

FAILURE

Cost of

failure large

Cost of

failure small

Cost of

failure large

Cost of

failure small

Very small scale

test

Very small scale

test

Small scale test

Very small scale

test

Very small scale

test

Very small scale

test

Small scale test

Large scale testSmall scale test

Very small

scale test

ImplementLarge scale test

Testing and Implementing a Change Idea

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Example of 3 Step Design in

Implementing the Ventilator Bundle

Integrate daily

goals with MDR

to identify

defects

Education

Baseline

Feedback on

compliance

check built into 1

hour scheduled vent

checks

Example of using 80% and 95% change concepts to initially reach a reliability of 80% then additionally using

a robust change concept (redundancy) to reach 95% reliability in the 4 elements of the ventilator bundle

(Baptist Memorial, Memphis)

Teaching and

awareness

5 Holding the Gains

• Deep and broad

understanding of what

it takes to sustain

change... reliability and

resilience in care

delivery ..

• Sensitive to operations

(Safety II )

• Acknowledge and

monitor spread

• Celebrate Success

11/29/2016

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Starting Labels of Reliability

• Chaotic process: Failure in greater than 20% of opportunities

• 80 or 90 % : 1 or 2 failures out of 10 opportunities(lacks consistent clear understanding of the process, 5 front line process users

can not easily articulate the process)

• 95% or better : 5 failures or less out of 100 opportunities(has some variation but 5 front line users can easily articulate the process)

(These are IHI definitions and are not meant to be the true mathematical equivalent)

Car service

Brakes Tyres Oil Filters

Car 1 Yes No Yes Yes

Car 2 Yes Yes Yes Yes

Car 3 Yes Yes No Yes



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Car service

• Brakes 100%

• Tyres 80%

• Oil 80%

• Filters 100%

• Overall 60%

4 times out of 10 you don’’’’t get a proper service

Aim for high reliability

• Regarding small

errors as a

symptom that

something is

wrong

Preoccupation

with failure

Preoccupation

with failure

• Paying attention

to what’s

happening on

the front-line

Sensitivity to

operations

Sensitivity to

operations• Encouraging

diversity in

experience,

perspective,

and opinion

Reluctance to

simplify

Reluctance to

simplify

• Capabilities to

detect, contain,

and bounce-back

from events

Commitment

to resilience

Commitment

to resilience• Pushing

decision

making down

to the front

line

Deference to

expertise

Deference to

expertise

Anticipate

Contain

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Move from safety 1 to safety 2

Things that

Are difficult

but go

right

Things that

go wrong

Early

completion

Excellent

innovation

Positive

surprises

Unwanted Outcome Planned Great outcome

Hollnagel E., Wears R.L. and Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net

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• If not

You…………………………………..

Who

Making it stick

• What have you changed in practice that has

been sustained?

• How do you think that happened?

• What are the key characteristics?

• Discuss with your neighbor

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Holding the gains

• Making it stick

• What have you changed in practice

that has been sustained?

• How do you think that happened?

• What are the key characteristics?

• Discuss with your neighbor

Profound Knowledge

Subject Matter Knowledge

What Prevents Action

�Let’s Change the Conversation

�Everyone knows what they don't want

�Let’s start to focus and describe what we want

�What would be happening if things were going

great and what behaviours get results?

�Need to be specific when solving people problems

�Create opportunities for teams to describe and develop their own solutions


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Be curious always

• IQ – Intelligence Quotient

–processing complex data sets and having

the mental capacity to problem solve at speed

• EQ – Emotional Quotient

–the ability to perceive, control and explain emotions; risk-

taking, creating resilience and empathy

• CQ – Curiosity Quotient

–inquisitive, open to new experiences, finding novelty exciting

Chamorro-Premuzic T. “Curiosity Is as Important as Intelligence.”

Harvard Business Review. Aug 27, 2014.

Share and Exchange

People at the center

Our contacts

[email protected] @sparklescot

[email protected] @peterlachman

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