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OXYJENNC O N S U L T I N G

The healthcare improvement leaders’ essential toolkit

An ISQua webinar presented by Mark Jennings,Oxyjenn Consulting Ltd

30th June 2017


Introduction

Mark JenningsMBA. BSc. CEng.

Managing DirectorOxyjenn Consulting

No interests to declare


Webinar Objectives

For participants to:

1. Understand the key approaches critical to making successful change

2. Be familiar with the essential tools in the improvement leaders toolkit

3. Be ready to apply the tools to your next project


The four key approaches critical to making successful change

and improvement in healthcare;

▪ Getting started: the three fundamental questions for all

improvement initiatives

▪ Generating solutions: collaborative strategy development

▪ Selecting opportunities: prioritisation by impact and ease

of implementation

▪ Knowing how you are doing: measuring progress and

impact

Followed by

▪ Questions and discussion

Outline


Who are you?


1.Getting Started


Three Fundamental Questions

What are we trying to achieve?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?


Model for Improvement

Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June 1994



Set AIMS that are measurable, time-specific, and apply to a defined population





Establish MEASURES to determine if a specific change leads to improvement






Select INTERVENTIONS most likely to result in improvement



“If you don't know where you are going, any road will get you there”


The Aim Statement

Helps you focus on what your project needs to accomplish. It provides a specific, measurable statement of intent. The aim should be:

• Clear and unambiguous, deliverableS - Specific• Observable outcomes of performance

Quantity, Quality, Cost, TimeM - Measurable• Realistic within the capabilities and

contraintsA – Achieveable

• Address a significant needR - Relevant• You have a target date for completion

• Now is an opportune time to undertake the project

T – Timebound• Project will stimulate all concerned to

actionE – Engaging• Written down for clarity, communication

and reviewR - Recorded


Clear and measurable aims?

Ensure timely completion of the assessment processAll patients to have a complete medication listManage the readmission rateLower staff sickness rateImprove the care of frequently admitted patients Fewer medication errorsImprove staff turnoverReduce patient fallsProvision of timely and appropriate care for stroke patients


“Some is not a number, soon is not a

time”

Don Berwick IHI, Boston

How good?

By when?


Clear and measurable aims?

Ensure timely completion of the assessment processAll patients to have a complete medication listManage the readmission rateLower staff sickness rateImprove the care of frequently admitted patients Fewer medication errorsImprove staff turnoverReduce patient fallsProvision of timely and appropriate care for stroke patients

How good?

By when?


For your project

Define a measurable aim



The PDSA Cycle






TEST the changes


Meeting rooms

Real world

Approve

Design Design Design Design

Implement !

Opinion

[Patient Safety First]


Meeting rooms

Real world


Implement

Approve

Test &

refine

Test &

refineTest &

refine

Design

Observation

data


Plan-Do-Study-Act

disciplined framework ensures every part is done every time

facilitates rapid prototyping and rolling out of new ideas


The usual approach


Change through small steps

Change ...with a clear purposeyou can learn from (without fear of failure)which is less exhaustingwith fewer unintended consequenceswhich builds engagement and optimism

Always ask.. What is the smallest test of change you can try?


Plan-Do-Study-Act






TEST the changes


2. Generating solutions


Driver Diagrams: Collaborative solution development


Most solutions /interventions ….

Aim: An improved

system

PrimaryDriver

PrimaryDriver

Change

Change

Change

SecondaryDriver

SecondaryDriver

SecondaryDriver

SecondaryDriver

SecondaryDriver

Driver Diagrams

CauseEffect

Drives

Change

Change

Driver DiagramWeight loss example

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat meals

Buy only 1

sandwich

Water bottle for

work bag

Fruit for dessert

Put away the

large glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Be more active

during the day

Do sport

Drink less alcohol

Substitute lower

calorie foods

Eat lessReduce

calories in

Increase

calories out

Take stairs

2 stone weight

loss in 6/12

20 % REDUCTION IN ADMISSIONS

FOR THE OVER 75s BY 2016

Reduce attendanceat A&E

Reduce conversion to admission

Utilise alternative options

Clinician education

Increase efficiency / streamlining

Best practice clinical management

Data focused plans

Patient education

SPA inreachto A&E / MAU

Utilise SPA

Make more use of paramedics

Work with third sector

Social services input

Better population health

Link to HWB priorities

Proactive mental health care

Optimise LTC management

Rapid discharge options from A&E

Home discharge

Non-home discharge

All GP referrals to be triaged by SPA

Medical team support on phone for paramedics

Extended scope paramedic roles

Increase community hospital beds

Social worker on call in A&E

Funding for volunteer home visitor training

Engagement meeting with local charitiesCauseEffect

Urgent care

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat meals

Buy only 1

sandwich

Water bottle for

work bag

Fruit for dessert

Put away large

wine glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Take stairs2 stone weight

loss in 6/12

Generate Change Ideas

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat meals

Buy only 1

sandwich

Water bottle for

work bag

Fruit for dessert

Put away large

wine glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Take stairs2 stone weight

loss in 6/12

Look for patterns

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat mealsBuy only 1

sandwich

Water bottle for

work bag

Fruit for dessertPut away large

wine glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Take stairs

Be more active during

the dayDo sport

Drink less alcohol

Substitute lower calorie

foods

Eat less

Marshall a mass of ideas

2 stone weight

loss in 6/12

Pedometer

Gym work out 3

days

Squash weekends

No pub weekdays

Take packed

lunch

Low fat meals

Buy only 1

sandwich

Water bottle for

work bag

Fruit for dessert

Put away large

wine glasses

Put cycling days

in diary

Cycling kit out

night before

Get rid of Oyster

card

Be more active

during the day

Do sport

Drink less alcohol

Substitute lower

calorie foods

Eat lessReduce

calories in

Increase

calories out

Take stairs

2 stone weight loss

in 6/12

Marshall amass of ideas

Prioritise

Surviving failure

We tend to plan assuming this

When all the evidence and our experience says it is like this

Gym workout 3

days per week

Buy only one sandwich

Take stairs

Survive failure:Try something else

Gym workout 3

days per week

Buy only one sandwich

Fruit for dessert

Take stairs

Take packed

lunch

Consolidate success:Try something else

Aim: An improved

system

PrimaryDriver

PrimaryDriver

Change

Change

Change

SecondaryDriver

SecondaryDriver

SecondaryDriver

SecondaryDriver

SecondaryDriver

Driver Diagrams

CauseEffect

Drives

Change

Change


Driver diagram

Patient Safety First campaign

Aim

Specific

interventions

Measures

bundle

M1

Designing quality improvement initiatives: The Action Effect Method, a structured approach identifying and articulating programme theory NWL CLARHC

That a person in xxxxexperiences care that is led by them and supported by professionals who know each other and who operate within a culture where they connect people to the strengths and resources in their community.

Give staff permission to get to know

someone

Positive risk taking

Operational changes

Coaching and mentoring

People power

Verbal referrals

Joint visits

Active listening

Someone takes overall responsibility – care coordination

Strengths based. What can an individual person do? Not

want can’t they do but what can they do. What are their strengths?

Using human and professional skills to assess risk

Only act if doing so adds value to the person.

Broadening understanding of staff, for example time to Shadow others and that this time is valued by managers.

Develop one common tool to identify and measure what is important to the person

Person versus professional expertise in balance.

Leadership and management which supports positive risk taking

Encourage individuals “people/patient/client” to take positive risk

Networking/educational events across organisations, similar to GP PLTs.

Develop LAC role. Embed LAC in ICT teams but also accept

that individual spends significant amounts of time in their community

Create an ICT team identity and a team plan

2gether to provide names and contact details

of local staff to GCS, so that staff link and

align to each of the existing 4 GCS ICT teams.

Shared operational and peer supervision.

Identify a lead professional for each person

who has more than 1 professional involved in

their care. Links to ICT case management

pilot .

Physically locate staff with ICT teams. The

building could belong to either organisation.

Not about changing the employer.

One referral centre for locality for all

referrals. Combine 2gether and GCS referral

centres into one location. To include referral

coordination. Overall aim would be to make

the person safe and then assign to relevant

staff (GCS or 2Gether) who do an

assessment based on understand. Centre

would receive referrals from people and

professionals including GPs and local

agencies. To include a share of the Adult

Help Desk. Could deliver signposting element of Care Bill.

Unified/compatible IT

Personal budgets and enhanced payments

Engagement and influencing

Engagement and influencing

Aim Best Possible

outcomes for mother and child

OutcomesImprove life outcomes:• Pre term• Still birth• LBW• Mortality• Morbidity

Improve experience:• Measures

from experience surveys

Best use of £ resources

Safe and Effective Care

PRIMARY DRIVERSAIM SECONDARY TERTIARY CHANGE IDEAS

Agreed pathways - midwifery led care[pre-conception to post-natal]

Define roles & responsibilities

Enhanced roles for MSWs

Reduce unwarranted variations in clinical behaviour

Risk assessment at least each trimester and post partum

Appropriate high risk pathways

Low risk pathways

Case loading

Review perinatal mental health practice & agree high risk pathways

Risk assessment tool

Service Specs & SDIPComplex case management protocol

& out of hospital care

High impact pre-conception advice

Effefctive & timely screening (ante & post)

Discuss with secondary/primary care

Refine pre-conception & intervention training with staff

Pharmacy referrals for booking

Skilled & available workforce. Learning as system. Quality improvement skills

Recruitment & Retention

Top Quality Clinical Governance

Glucose tolerance screening

Safe reportingSafe Culture

Effective staff supervision

Develop culture of excellence

Workforce capacity review

CNST action plan

Redefine quality metrics

AIM GENERIC PRIMARY DRIVERS

ANY AIM

Premises

Leadership and culture

Workforce

Collaboration and integration

Alternative provision

Local leadership and culture demonstrate support for aim and quality improvement

Care delivered in premises that are appropriate, safe and efficient

Alternatives to conventional care delivery (including self-care) have been

considered

System partners collaborate to improve care and integrate delivery

Workforce planning and development to ensure services delivered by an appropriately skilled workforce

Methods to manage demand (including stratification and segmentation) have

been considered

Information Accurate information available to support timely clinical decision-making

Demand management

PROMPTS

Driver Diagram Checklist


Driver Diagrams

Benefits ...

✓ build complex strategy

✓ immediate

✓ visual

✓ collaborative

Different scenarios ...

1. Helps generate change ideas

2. Marshall a mass of change ideas

3. Survive failure / the unexpected

✓ hypothesis

✓ avoid “silver bullet” thinking

✓ highlights overlooked ideas


For your project

Draw a driver diagram

Primary

DriversOutcome

Secondary

Drivers

Process

Changes

Aim: An

improved

system

P. Driver

S. Driver 1Change 1

P. Driver

S. Driver 2

S. Driver 3

S. Driver 1

S. Driver 2

Change 2

Change 3

EFFECT CAUSE


3. Selecting Opportunities


IMPACT

DO-

ABILITY

HIGH

HIGH

LOW

LOW

Prioritisation Matrix


IMPACT

DO-

ABILITY

HIGH

HIGH

LOW

LOW

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=E4x5PkAiIWQK9M&tbnid=-r0rxr9BmNb37M:&ved=0CAUQjRw&url=http://en.wikipedia.org/wiki/File:Question_mark_(black_on_white).png&ei=9nOYU7ClIauA7Qau84DwBQ&bvm=bv.68693194,d.ZGU&psig=AFQjCNETpqVuoxcC9_8PLYO3UqEy7D0uXA&ust=1402586472536057


© 2011 Oxyjenn Consulting D R A F T

IMPACT

IMP

LEM

ENTA

TIO

N

HIGHER

LOWER

HARDER EASIER

Converting emergency admissions for particular

presentations to ‘day cases’

Comprehensive ambulatory emergency care service for a wide

range of emergency presentations

Proactive outreach case management by district nurses and community

matrons

Integrated health and social care via a Care Trust

Integrated urgent care in general practice

Community Virtual wards

Acute visiting scheme in general practice

Extended access hours intermediate care response

teams

Care bundles /pathways for all emergency and

elective careIntegrated intermediate

care within general support for older people

GPs in A&E

Focus on managing LoSand expediting discharge

Improved clinical decision-making in A&E (use of

senior staff earlier in the process )

Emergency care practitioners/paramedics

on 999 ambulances

Classifying potential interventions


4. Knowing how you are doing


“We’re pressed for time, so we’ll be jumping to conclusions”


Meeting rooms

Real world


Implement

Approve

Test &

refine

Test &

refineTest &

refine

Design

Observation

data


Meeting rooms

Real world


Implement

Approve

Test &

refine

Test &

refineTest &

refine

Design

Measurement


▪ Why measure ?

▪ What to measure?

▪ How to use measures?

Dimensions of measurement


The three purposes of measurement

• eg A-B comparison, average, huge dataset

Research

• eg one-to-many benchmarking comparison, average, large dataset

Judgement

• eg continual analysis of single changing process over time

Improvement

Why measure ?


Mindsets

Research

Improvement

Judgement


Research Judgement Improvement

GoalNew knowledge (not its applicability)

ComparisonReward / punishmentSpur for change

Processunderstanding

Evaluating a change

Hypothesis Fixed None Multiple and flexible

Measures Many Very few Few

Time period Long, past Long/medium, past Short, current

Sample Large Large Small

Confounders

Measure or control Describe and try to measure

Consider but rarely measured

Risks in improvemen

t settings

Ignores time based variation

Over-engineers data collection

Ignores time based variation

Over-reaction to natural variation

Incorrectlyperceived as ‘inferior statistics’

Measurement mindsets

Based on L Solberg, G Mosser and S McDonald (1997) The Three Faces of Performance Measurement: Improvement,

Accountability and Research, Journal on Quality Improvement, 23 (3): 135 - 147.


Primary

DriversOutcome

Secondary

Drivers

Ideas for Process

Changes

AIM:

A New

ME!

Calories In

Limit daily

intake

Track

Calories

Calories

Out

Substitute

low calorie

foods

Avoid

alcohol

Work out 5

days

Bike to

work

Plan

Meals

Drink H2O

Not Soda

drives

drives

drives

drives

drives

drives

drives

drives

• Weight

• BMI

• Body Fat

• Waist size

• Daily calorie

count

• Exercise

calorie count

• Days between

workouts

• Avg drinks/

week

• Running

calorie total

• % of

opportunities

used

• Sodas/

week

• Meals off-

plan/week

• Avg cal/day

Exercise

Fidgiting

Hacky

Sack in

office

Percent of days

on bike

Etc...

Measures –plotted on driver diagram


What to measure


What to measure?

Structure Process Outcome

Avedis Donabedian

‘Outcomes remain the ultimate validators of the

effectiveness and quality of medical care’ but they

‘must be used with discrimination’

The environment

in which care

occurs

What care is

delivered, and

how

The impact on

patients and the

population


What to measure?


eg Structure indicators…

• patients treated on a specialist stroke unit

• attributes relating to clinicians (such as certification,

training)

• staffing ratios

• surgical volumes

• access to equipment eg, MRI scanners.


What to measure?


Pros ConsPros Cons

Expedient / inexpensive

Data often available

Efficient – one indicator may relate to

several outcomes

Often evidence-based

Pros Cons

Expedient / inexpensive Limited number of measures,

especially for ambulatory care

Data often available Not always actionable – eg, a small

hospital cannot readily become a

high-volume centre

Efficient – one indicator may relate to

several outcomes

Work better as markers of aggregate

performance than performance of

individual providers

Often evidence-based Less appealing to many than

outcome indicators



What to measure?

eg Process indicators…

• antenatal assessment <13 weeks

• physical checks in people with serious mental

illness

• structured education for people with diabetes

• people with stroke reviewed <6 months of

leaving hospital

• psychological support after stroke


What to measure?


Pros ConsPros Cons

Most evidence-based indicators are

process related

Direct measure of quality

Reflect care that patients receive

Easily measured, data collection easier

Easy to interpret

Not subject to time lags

Don’t require risk adjustment

Actionable, therefore useful for quality

improvement, performance

assessment

Pros Cons

Most evidence-based indicators are

process related

Often too specific, narrow

Direct measure of quality Links with outcomes variable/unclear

Reflect care that patients receive Can become tick box exercise

Easily measured, data collection easier Potentially subject to manipulation

Easy to interpret May have little appeal for patients

Not subject to time lags

Don’t require risk adjustment

Actionable, therefore useful for quality

improvement, performance

assessment


What to measure?

eg Outcome indicators…

• recovery following talking therapies

• under 75 mortality rate from cancer

• hospital admissions for ambulatory care-sensitive

conditions

• mortality within 30 days of hospital admission for stroke

• emergency re-admissions within 30 days of discharge

from hospital

• health-related quality of life for people with long-term

conditions

• patient experience of GP out-of-hours services

• Patient Reported Outcome Measures



What to measure?

Pros ConsPros Cons

Face validity

Reflect all processes of care

Effective where close causal link exists

between intervention & outcome

Measurement and feedback can drive

improvement

Not easily manipulated

Effectively applied in surgery – eg,

cardiac surgery


Pros Cons

Face validity Link to care quality variable / unclear –

modern medicine can’t cure everything

Reflect all processes of care Affected by factors unrelated to care

quality

Effective where close causal link exists

between intervention & outcome

Attribution often difficult/uncertain

Measurement and feedback can drive

improvement

Measurement challenges: - risk

adjustment - good-quality clinical data -

outcomes often low-frequency events

Not easily manipulated Potential for risk avoidance

Effectively applied in surgery – eg,

cardiac surgery

Limited use in primary, medical,

ambulatory care

Time lag between care & outcome


Explaining outcomes…


Category of explanation

Sources of variation

Differences in patient types

Patient characteristics – eg, co-morbidity, severity, socio-economic status

Impact of external factors

eg quality of primary, community, ambulance care, local availability of hospices

Measurement challenges

Ascertaining risk factors, availability of data, method of analysis – eg, method of risk adjustment

Chance Random variation, influenced by numbers of cases and frequency of


What to measure?


“Intermediate outcomes”

• a common solution

• properties of both process & outcome

• but be careful to acknowledge it’s

not ‘the ultimate outcome’


OU

TP

UT

S

HUMAN

FACTORS

HUMAN

FACTORS

INTERNAL PROCESSES & PROCECEDURES

INP

UT

S

EXTERNAL

FACTORS

Process Measure

Ou

tco

me

Measu

re

What to measure?

Is it being done?

Is it working?

Is it in place?

Structure

Measure


Metrics for different audiences

Board

Service managers

Project managers

Frontline staff

Focus on

outcome

Focus on

processRelevant process +

outcome measures

Relevant process +

outcome measures

Higher level outcome

measures

Highest level outcome

measures


Balancing measures


OU

TP

UT

S

HUMAN

FACTORS

HUMAN

FACTORS

INTERNAL PROCESSES & PROCECEDURES

INP

UT

S

EXTERNAL

FACTORS

Process Measure(s)

Ou

tco

me

Measu

re(s)

Balancing Measure(s)

What to measure?

Is it being done?

Is it working?

Unintended consequences?

Is it in place?

Structure

Measure(s)


How to use measures


How do you look at your data ?


The Problem

Aggregated data presented in

tabular formats or with summary

statistics, will not help you measure

the impact of improvement efforts.

Aggregated data can only lead to

judgment, not to improvement.


Waiting time results

70

35

0

10

20

30

40

50

60

70

80

Avg

Before

Change

Avg After

Change

Wa

it T

ime

(m

in.)


Waiting time results0

10

20304050

607080

90100

date Jan

Feb

Mar Apr

May Jun

Jul

Aug

Sep

Oct

Nov Dec

Change

Made

Cycl

e Ti

me

(min

.)

010

20304050

607080

90100

dat

e

Jan

Feb

Mar

Ap

r

May

Jun

Jul

Au

g

Sep Oct

No

v

Dec

Change

Made

Cyc

le T

ime

(min

.)

Unit 1

Unit 3

010

20304050

607080

90100

dat

e

Jan

Feb

Mar

Ap

r

May Jun

Jul

Au

g

Sep Oct

No

v

Dec

Change

MadeCyc

le T

ime

(min

.)

Unit 270

35

0

10

20

30

40

50

60

70

80

Avg

Before

Change

Avg After

Change

Wa

it T

ime

(m

in.)


Why Time Is Important for Measurement

Aggregate measures alone do not lead to predictions about future performance or insights to explain past variations

Displaying data over time allows us to make informed predictions, and thus manage effectively

© Richard Scoville & I.H.I.


Enumerative Dynamic


Protocol

introduced

Pre op

briefingsLetter

from

Clinical

Director

Pharmacy

included

% surgical patients receiving Prophylactic Antibiotics

0

10

20

30

40

50

60

70

80

90

100

Ap

r-07

Ma

y-0

7

Jun-0

7

Ju

l-07

Au

g-0

7

Sep-0

7

Oct-

07

No

v-0

7

De

c-0

7

Ja

n-0

8

Feb

-08

Ma

r-08

Ap

r-08

Ma

y-0

8

% r

eco

nciled

Run Chart






TEST the changes


Questions and

Discussion


Mark Jennings

[email protected]

+44 (0)777 1996410

mailto:[email protected]

the healthcare improvement - isqua · the healthcare improvement leaders’ essential toolkit an...

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