transforming care. house keeping fire alarms / fire escapes toilets mobile phones
TRANSCRIPT
Transforming Care
Transforming Care
Transforming Care
House keeping
• Fire alarms / Fire escapes
• Toilets
• Mobile phones
Transforming Care
Des Brown, Service Improvement Manager, Transformation & Change TeamNational Leadership and Innovation Agency for Healthcare (NLIAH)[email protected] 595 631
Transforming Care
The reality in practice…
Transforming Care
The reality in practice…
Josie King....
Transforming Care
Deming’s thoughts on TransformationMetanoia:
• Reorientation of one’s way of life
(The New Economics. Deming, p. 95, 1993)
• Begins with individual
• More than a change
• Develop new habits of mind
Transforming Care
Transformative Learning
• Not spontaneous (requires work and discipline)
• Creates new meaning to life, events, facts, interactions with others
• Results in change in perception; knowing which requires different action or structure
• What is the learning that creates a new habit of mind?
– Change perspectives and paradigms
– Challenge and validate assumptions
– Critical self-reflection
– Include and integrate experiences
Transforming Care
Aims and objectives
Transforming Care
Transforming CareAim - To transform the quality and safety of patient care across Wales
Specific objectives• To increase the amount of time healthcare staff spend in direct / value
added patient care to 70% • To reduce locally defined adverse events by 50%• Increase patient satisfaction to at least 95% • Increase staff satisfaction to at least 95%
Transforming Care
Transforming CareAim - To transform the quality and safety of patient care acrossWalesUnderlying principle: To engage staff of all disciplines and at everylevel within NHS organisations in improving the experience andoutcomes of care for patients • by empowering healthcare staff to continuously improve the quality,
safety and fundamentals of the care they provide to patients and service users
• by engaging multidisciplinary staff at every level in the planning, testing, monitoring, implementation and spread
• by providing staff with the tools, techniques and support they need to improve the experience and care of patients, carers and service users
• by ensuring each improvement is sustainable and can be spread as far as possible
• by building a vibrant network across Wales to share learning and provide peer support, coaching and mentoring
Transforming CarePRIMARY DRIVERSPRIMARY DRIVERS SECONDARY DRIVERS/INTERVENTIONSSECONDARY DRIVERS/INTERVENTIONS
Transformational
Leadership
Transformational
Leadership
- Establish, oversee and communicate system level aims for improvement - Align measures, strategy, projects and leadership learning system - Channel leadership attention to quality improvement and safety - Build the right team - Engage medical staff in improving care at all levels - Align quality projects to finance
- Establish, oversee and communicate system level aims for improvement - Align measures, strategy, projects and leadership learning system - Channel leadership attention to quality improvement and safety - Build the right team - Engage medical staff in improving care at all levels - Align quality projects to finance
Releasing Time to Care
(Value-added care)
Releasing Time to Care
(Value-added care)
Safety and
Reliability
Safety and
Reliability
Teamwork and
Vitality
Teamwork and
Vitality
Patient and
Family Centred
Care
Patient and
Family Centred
Care
Increase patient satisfaction to at least 95% - Support and involve patients and families - Create patient-centred healing environments - Ensure patients’ physical comfort - Optimise care transitions to home or elsewhere - Maintain patients’ Privacy and Dignity - Provide emotional and spiritual support
Increase patient satisfaction to at least 95% - Support and involve patients and families - Create patient-centred healing environments - Ensure patients’ physical comfort - Optimise care transitions to home or elsewhere - Maintain patients’ Privacy and Dignity - Provide emotional and spiritual support
Increase staff satisfaction to at least 95% - Empower ward managers to create teams with the ability and authority to act and transform care. - Build capability for Innovation and improvement in frontline staff and middle managers - Optimise communication across the care team - Improve physical environment for staff and reduce injuries
Increase staff satisfaction to at least 95% - Empower ward managers to create teams with the ability and authority to act and transform care. - Build capability for Innovation and improvement in frontline staff and middle managers - Optimise communication across the care team - Improve physical environment for staff and reduce injuries
Reduce defined adverse events* in participating units by 50% - Improve the reliability of core processes
*(decisions regarding the choice of adverse events to be negotiated locally by the executive sponsor and the frontline unit staff)
Reduce defined adverse events* in participating units by 50% - Improve the reliability of core processes
*(decisions regarding the choice of adverse events to be negotiated locally by the executive sponsor and the frontline unit staff)
Increase the percentage of time healthcare staff spend in direct/value-added care to 70%
- Understand measurement for improvement - ‘knowing how we’re doing’ - Empower staff to develop a ‘well organised ward’ - Enable staff to identify ‘patient status at a glance’
Increase the percentage of time healthcare staff spend in direct/value-added care to 70%
- Understand measurement for improvement - ‘knowing how we’re doing’ - Empower staff to develop a ‘well organised ward’ - Enable staff to identify ‘patient status at a glance’
To transform the quality and
safety of patient care across
Wales
To transform the quality and
safety of patient care across
Wales
AIMAIM
Transforming Care
Transforming Care
What does a Transforming Care environment look like?
Observations include:
• Much calmer atmosphere, making it a more pleasant place to work
• Reduction in short-term staff sickness
• Improved communication with doctors, AHPs and other services like Catering, Cleaning and Pharmacy
• Increased enthusiasm and motivation of staff
• Lots of new ideas for improvements from staff
• Sense of control ‘our work environment, we can change it’
Transforming Care
Transforming Care
Learning from industry
Transforming Care
Transforming Care
Multi-disciplinary teams
“We have a passion to achieve results and continuously improve”
By:
• Generating ideas - PDSAs
• Lean initiatives
• Effective team working
• Improved relationships
• Improve quality of patient care and the patient experience
Transforming Care
Direct Care Time
Motion Admin Discussion Handovers InformationRoles
Opportunity to increase safety and reliability of
care
Rol
e T
ime
(e.g
. n
urse
)
Total Time
“Everything I need to do my job is
conveniently located”
I am not interrupted by people requesting
information or looking for things
‘’Handovers are concise, timely and
provide all the information I need”
‘It is clear to everyone who is
responsible for what”
‘We have the information we need
to solve our own problems, and find out if we were successful”
How do we increase Direct Care Time?
Transforming Care
Transforming CareTransforming Care
On 2 wards at Withybush, nurses are now spending 1/3rd moretime with patients. Up from 46% before TC to 60% in Nov 08 andthen 63% in July 09 (sustained and continuing improvement!)
On 3 wards at Royal Glamorgan nurses are now spending 1/6th more time with patients. Up from 42% to 49%
On a mental health ward in Hywel Dda, nurses are now spendingover twice as much time with patients. Up from 42% before TC to 89%
Some headline Welsh results to date
Transforming Care
Patient team members and stories
Ward 9 Comparisons Percentage of Time by Activity
16.5
7.7
10.712.9
9.9
42.3
19.8
2.5
6.2
12.9
7.7
50.9
15.4
3.6 3.1
13.8
5.0
59.1
4.8 4.9
8.2
16.3
5.5
60.2
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
Discussion Interruptions Motion Other Admin Patient Care
%ag
e of
Tim
e May-08
Oct-08
Feb-09
Jul-09
Ward 14 (was 11)
0
12
3
4
56
7
89
10
30/06
/2008
21/07
/2008
11/08
/2008
01/09
/2008
22/09
/2008
13/10
/2008
03/11
/2008
24/11
/2008
15/12
/2008
05/01
/2009
26/01
/2009
08/02
/2009
14/02
/2009
02/03
/2009
23/03
/2009
13/04
/2009
04/05
/2009
25/05
/2009
15/06
/2009
Period
Indi
vidu
al V
alue
Special Cause Flag
556 Number of days since a Pressure Ulcer developed on Anglesey ward
Winners of “Improving Quality through better use of resources” NHS awards 2009
Transforming Care
Other typical resultsOrders of supplies, drugs etc. reduced by up to £1000s per ward per year
Medicine round time reduced by 63%
Handover time reduced by 50%, but quality increased
Observations reliability score increased by 70%
Meal wastage rate down from 7% to 1% (£10,000 of unnecessary annual meal requests identified in one ward)
Interruptions reduced from 114 to 64 per shift (per nurse)
Transforming Care
Transforming Care
1000 Lives Plus
• 1000 Lives Plus is a national improvement programme, supporting organisations and individuals, to deliver the highest quality and safest healthcare for the people of Wales
Transforming Care
Before
After
Transforming Care
“Go and see…”
Transforming Care
National learning community
Transforming Care
Making the connections
• Engaging the whole team
• Transforming Care
Transforming Care
The Model for Improvement
Transforming Care
Organisational transformation…
• Vision
• Bold Aims
• Relentless execution of small repeated tests of large change or in other words…
Transforming Care
Improvement requires a clear aim,
…measurement and action!
Transforming Care
What are we trying toWhat are we trying toaccomplish?accomplish?
How will we know that aHow will we know that achange is an improvement?change is an improvement?
What changes can we make that willWhat changes can we make that willresult in the improvements we seek?result in the improvements we seek?
Act Plan
Study Do
A model for improvement...Aims
Measurement
Ideas, evidence, hunches,
other people etc.
Thethree
fundamentalquestions forimprovement
The fourthquestion:
how to make changes
Langley, Nolan et al 1996
Transforming Care
• The power of the PDSA as an improvement tool / technique
• Reiterate the importance of testing change
• No test can begin too small
• Build upon learning from test
• Factor reliability into processes/systems
• Plan Spread model
Aim
Transforming Care
• A radical change to a system /process
• Full blown trust-wide implementation
• Mini projects (monumental proportion)
• Top down directives
PDSAs' ‘test’ a proposed change
What they are not…
Transforming Care
• Hunches and Theories
• Gap in knowledge
• Set about testing your theory
• Cause and Effect
Where to begin?
Transforming Care
Repeated Use of the PDSA Cycle
Hunches, theories, ideas
Changes that result in improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very small scale test
Follow-up tests
Wide-scale tests of change
Implementation of Change
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Transforming Care
Overall aim – To reduce the incidence of hospital acquired pressure within the organisation by 50% by xxxxxx
Multiple PDSA ramps
Transforming Care
Example of a PDSA
Worksheet for testing change - Cycle No 1 : General wards 9 and 4Aim: To improve overall patient flow within the hospital and contribute to timely, effective treatment, management and discharge of patients
Describe your first (or next) test of change Persons responsible
When to be done
Where to be done
1) To develop a patient information sheet that will inform patients on admission regarding the estimated date of their discharge and the arrangements that will be made in anticipation of this discharge date.2) To test the use of the form with one nurse and one patient per ward
JD and RW
W/c18 April
Ward 4 & Ward 9
Plan
List the tasks needed to set up this test of changePerson Responsible
When to be done
Where to be done
1) Identify similar information from other Trusts 2) Personalise the leaflets to meet the local needs3) Prepare a draft4) Identify a nurse and patient who are prepared to participate.5) Inform them of the reasons behind the Estimated Date of Discharge and the purpose of the information leaflet
JD W/c18 April
Predict what will happen during the test Measures to determine if prediction succeeds
The patient and nurse will understand the reasons for estimating the date of discharge.They will understand and agree with the content / information, layout and format of the leaflet.
Views of patients and professionals will be sought
Transforming Care
• Do Observe and record what actually happens when you
run the test
• Study Describe the measured results and how they compared
to the predictions
• Act Decide what modifications to the plan will be made for
the next cycle from what you learned
Transforming Care
• One ward
• One patient
• One doctor
• One nurse
• One day / shift
Small scale tests of change on
Transforming Care
1 3 5 Spread
The spread
Transforming Care
What are we trying toWhat are we trying toaccomplish?accomplish?
How will we know that aHow will we know that achange is an improvement?change is an improvement?
What changes can we make that willWhat changes can we make that willresult in the improvements we seek ?result in the improvements we seek ?
Act Plan
Study Do
Aims
Measurement
Ideas, evidence, hunches,
other people etc.
Thethree
fundamentalquestions forimprovement
The fourthquestion:
how to make changes
Langley, Nolan et al 1996
A model for improvement
Transforming Care
Quantitative:• Outcome measures• Process measures• Balancing • Diagnostics
Qualitative:• Success stories• Patient stories
Use of measurement for learning
Transforming Care
• Outcome Measures
• Results – system level or process level
• Process Measures
• Inform changes to the system
• Balancing Measures
• Signal – robbing Peter to pay Paul
Types of measures
Transforming Care
Aim - To acquire a green cross or decrease the numberof red squares (time between events)
• No new case identified
• New case identified
• Admitted with or transferred from another unit with e.g. pressure ulcer
Safety cross
Transforming Care
• Hitting targets but missing the point
• Policies and protocols in place, but not always in practice…?
• Build reliability into your processes
• Sustainability and spread
• Focus on data for improvement
• Achieve targets as a by-product of a strong quality and safety culture
To conclude
Transforming Care
What are we trying toWhat are we trying toaccomplish?accomplish?
How will we know that aHow will we know that achange is an improvement?change is an improvement?
What changes can we make that willWhat changes can we make that willresult in the improvements we seek ?result in the improvements we seek ?
Act Plan
Study Do
Aims
Measurement
Ideas, evidence, hunches,
other people etc.
Thethree
fundamentalquestions forimprovement
The fourthquestion:
how to make changes
Langley, Nolan et al 1996
A model for improvement
Transforming Care
Next steps
Transforming Care
Ward/Team preparation• Develop ward implementation plan (agree who’ll do what,
when, considering off duties etc.)
• Brief everyone on their role in Transforming Care
• Ward/Team need to develop a vision and start thinking about measures of your progress against it
• Do 12 hours of activity follow to establish baseline Direct Care Time % (DCT). Facilitators see NLIAH for help if needed
• Carry out video waste walks and take photos of the ward
Transforming Care
‘A compelling statement that tells everyone what yourambition for your ward is’
• Key questions to consider:• What would a perfect ward /team environment look
like?• How would it feel to work in?• What would patients say about it?• How would clinicians and managers describe your
ward/team?
Describe in terms of quality, safety, efficiency and cost
Ward/Team vision
Transforming Care
• Display it in a prominent place in the ward
• The ward vision should be a focal point for the programme as you strive to make it a reality
• The ward vision can be used to help the team to prioritise what to improve first
• It will give you ideas for what to measure in the first module of RTTC (‘Knowing How We’re Doing’)
What do we do with the ward vision?
Transforming Care
• Activity follow is one of the key tools of Transforming Care. It’s done by nurses to nurses (though it could be adapted for use by AHPs)
• It gives you a Direct Care Time %, so you know how much time nurses on your ward spend with patients
• Activity follow should be done at the beginning and end of the RTTC section of Transforming Care and at least every 6 months thereafter
Activity follow
Transforming Care
Summary
Transforming Care
• Raise awareness of Transforming Care
• At executive level
• Frontline staff
• Patients, families & carers
• Align the work with what’s already in progress
• Develop an infrastructure to support this work or build on existing structures
• Get the right team on the bus
• Go with the willing
• Get baseline measurement in place
What do you need to do now?
Transforming Care
• We want to hear from all of you
– What three things are you going to do by next Tuesday to take TC forward in your organisation?
– What will be your first tests of change?
– Think ahead tell us how your organisation has changed…what’s different? Be succinct!
Action planning and report out
Transforming Care
Coffee Break