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Setting up an organisation-wide quality
improvement programme
- everything you need to know
in three hours
bull After this session participants will
bull Understand the QI needs and opportunities of your organisation and
how to successfully implement a QI programme
bull Have learnt how to develop structured QI training to upskill and
empower your staff and support their work
bull Have heard how mentoring coaching and good leadership can
dramatically enhance success and how you can deliver this with limited
resources
bull Have a ready to implement action plan to harness the potential of
frontline staff to meet your organisationrsquos healthcare improvement
objectives
Agenda
bull Welcome and introductions
bull Icebreaker
bull Organisational case study East London Foundation Trustrsquos
Quality Improvement journey
bull Break
bull Wake up exercise
bull Engaging people
bull Evaluating organisational quality improvement
bull Discussion and questions and a final exercise
Introducing our speakers
Mareeni Raymond GP Clinical Advisor for BMJ Quality
Aidan Fowler Consultant Surgeon IA ExecDirector UHBristol
Amar Shah Associate Medical Director for Quality Improvement and
Consultant forensic psychiatrist at East London NHS Foundation Trust
Nikita Kanani GP and QI Lead Faculty of Medical Leadership and
Management UK
Rob Bethune Locum Consultant Surgeon Royal Devon and Exeter Hospital
and Clinical Advisor to the South West Academic Health Science
Network
Conflicts of Interests - None
Aidan Fowler
A quick exercise to start us off
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
Act Plan
Study Do
Used with permission Associates in Process Improvement
Very simple exercise
Form a circle of ten people
Aim is to clap in turn and to complete four rounds of the circle
Need to time the complete cycle
No one should clap at the same time as another
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
bull After this session participants will
bull Understand the QI needs and opportunities of your organisation and
how to successfully implement a QI programme
bull Have learnt how to develop structured QI training to upskill and
empower your staff and support their work
bull Have heard how mentoring coaching and good leadership can
dramatically enhance success and how you can deliver this with limited
resources
bull Have a ready to implement action plan to harness the potential of
frontline staff to meet your organisationrsquos healthcare improvement
objectives
Agenda
bull Welcome and introductions
bull Icebreaker
bull Organisational case study East London Foundation Trustrsquos
Quality Improvement journey
bull Break
bull Wake up exercise
bull Engaging people
bull Evaluating organisational quality improvement
bull Discussion and questions and a final exercise
Introducing our speakers
Mareeni Raymond GP Clinical Advisor for BMJ Quality
Aidan Fowler Consultant Surgeon IA ExecDirector UHBristol
Amar Shah Associate Medical Director for Quality Improvement and
Consultant forensic psychiatrist at East London NHS Foundation Trust
Nikita Kanani GP and QI Lead Faculty of Medical Leadership and
Management UK
Rob Bethune Locum Consultant Surgeon Royal Devon and Exeter Hospital
and Clinical Advisor to the South West Academic Health Science
Network
Conflicts of Interests - None
Aidan Fowler
A quick exercise to start us off
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
Act Plan
Study Do
Used with permission Associates in Process Improvement
Very simple exercise
Form a circle of ten people
Aim is to clap in turn and to complete four rounds of the circle
Need to time the complete cycle
No one should clap at the same time as another
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Agenda
bull Welcome and introductions
bull Icebreaker
bull Organisational case study East London Foundation Trustrsquos
Quality Improvement journey
bull Break
bull Wake up exercise
bull Engaging people
bull Evaluating organisational quality improvement
bull Discussion and questions and a final exercise
Introducing our speakers
Mareeni Raymond GP Clinical Advisor for BMJ Quality
Aidan Fowler Consultant Surgeon IA ExecDirector UHBristol
Amar Shah Associate Medical Director for Quality Improvement and
Consultant forensic psychiatrist at East London NHS Foundation Trust
Nikita Kanani GP and QI Lead Faculty of Medical Leadership and
Management UK
Rob Bethune Locum Consultant Surgeon Royal Devon and Exeter Hospital
and Clinical Advisor to the South West Academic Health Science
Network
Conflicts of Interests - None
Aidan Fowler
A quick exercise to start us off
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
Act Plan
Study Do
Used with permission Associates in Process Improvement
Very simple exercise
Form a circle of ten people
Aim is to clap in turn and to complete four rounds of the circle
Need to time the complete cycle
No one should clap at the same time as another
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Introducing our speakers
Mareeni Raymond GP Clinical Advisor for BMJ Quality
Aidan Fowler Consultant Surgeon IA ExecDirector UHBristol
Amar Shah Associate Medical Director for Quality Improvement and
Consultant forensic psychiatrist at East London NHS Foundation Trust
Nikita Kanani GP and QI Lead Faculty of Medical Leadership and
Management UK
Rob Bethune Locum Consultant Surgeon Royal Devon and Exeter Hospital
and Clinical Advisor to the South West Academic Health Science
Network
Conflicts of Interests - None
Aidan Fowler
A quick exercise to start us off
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
Act Plan
Study Do
Used with permission Associates in Process Improvement
Very simple exercise
Form a circle of ten people
Aim is to clap in turn and to complete four rounds of the circle
Need to time the complete cycle
No one should clap at the same time as another
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Aidan Fowler
A quick exercise to start us off
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
Act Plan
Study Do
Used with permission Associates in Process Improvement
Very simple exercise
Form a circle of ten people
Aim is to clap in turn and to complete four rounds of the circle
Need to time the complete cycle
No one should clap at the same time as another
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
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
Act Plan
Study Do
Used with permission Associates in Process Improvement
Very simple exercise
Form a circle of ten people
Aim is to clap in turn and to complete four rounds of the circle
Need to time the complete cycle
No one should clap at the same time as another
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Very simple exercise
Form a circle of ten people
Aim is to clap in turn and to complete four rounds of the circle
Need to time the complete cycle
No one should clap at the same time as another
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Dr Amar Shah (Associate Medical Director for QI)
James Innes (Head of Quality Improvement)
Tsana Rawson (QI fellow)
Dr Genevieve Holt (QI fellow)
Dr Juliette Brown (QI fellow)
Organisational case studyEast London NHS Foundation Trustrsquos Quality Improvement journey
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Our quality
improvement programme
web qielftnhsuk
email qielftnhsuk
ELFT_QI Conflicts of interest None
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Mental health servicesNewham Tower Hamlets City amp Hackney Luton amp Bedford
Forensic servicesAll above amp Waltham Forest Redbridge Barking amp Dagenham Havering
Child amp Adolescent services including tier 4 inpatient service
Regional Mother amp Baby unit
Community health services Newham
Urgent care centre Newham
IAPTNewham Richmond and Luton
Speech amp LanguageBarnet
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Challenges and opportunities in East London
Cultural diversity Social deprivationGeographical
diversityCommissioning
arrangements
Financial stability and strong
assurance systems
ELFT_QI
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Our quality
improvement programme
Why
ELFT_QI
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
The strategic case for change
Make quality our absolute priority
bull Improving quality of care is our core purpose
bull Of greatest importance to all our stakeholders
bull Build on the excellent work already happening to improve quality
National drivers
bull The need to focus on a more compassionate caring service with patients first and foremost
bull More structured and bottom-up approach to improvement
Enable our staff to lead change
bull The desire to engage free and support our staff to innovate and drive change
bull Engaged and motivated staff leads to improved patient outcomes
The economic climate
bull The need to do more with less
ndash improving quality whilst reducing cost
ELFT_QI
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
The culture we want to nurture
Patients carers and families at the heart of all we do
A listening and learning
organisation
Empowering staff to drive improvement
Increasing transparency and openness
Re-balancing quality control assurance and improvement
ELFT_QI
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Our quality
improvement programme
How
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Build improvement
capability
Alignment
QI Projects
1 Launch event amp roadshows2 Microsite3 Using the power of narrative4 Celebrate successes5 Network of champions ambassadors6 Learning events
1 Initial assessment of alignment amp capability2 Recruiting central QI team3 Online training4 Face-to-face training5 Follow-up coaching on projects6 Develop in-house training for 2016 onwards
1 Align all projects with improvement aims2 Align team service goals with improvement aims3 Align all corporate and support systems4 Patient and carer involvement in all improvement work5 Embed improvement within management structures
Reducing Harm by 30 every year1 Reduce harm from inpatient violence2 Reduce harm from falls3 Reduce harm from pressure ulcers4 Reduce harm from medication errors5 Reduce harm from restraints
Right care right place right time1 Improving patient and carer experience2 Reliable delivery of evidence-based care3 Reducing delays and inefficiencies in the system4 Improving access to care at the right location
ELFT_QI
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
STARTING TO BUILD THE WILL
bull The events led the trust to question whether it had the right processes in place to deliver quality care
bull Robust assurancebull Staff and patient experience feedback not
very goodbull Arrival of MD from NPSA who made a
case for more co-ordinated and systemic trust wide approach
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
QI microsite the online hub for the programme qieastlondonnhsuk
Staff and service user newsletter reaches 4000 people every month
QI launch event and roadshows attended by over 1000 staff service users and carers
Bespoke QI learning events for staff service users commissioners governors
ELFT_QI
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
35000page views of the QI microsite in the last year
our one-stop shop for QI
built and managed by the QI team total cost pound300
qielftnhsuk
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Introducing microsite 20
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
1000Staff service users carers Governors
commissioners engaged in the first 4 months of the programme
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Bespoke learning sessions
Specialist services
leadership
Service users and carers
Finance team
Health visitorsNursing students
Band 3 nursing staff
Psychology trainees
Trainee doctorsExternal partners
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
5000staff receiving the monthly QI e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
Percentage of staff opening the e-newsletter
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will
550local services receiving the quarterly paper
newsletter including GP practices and voluntary sector organisations
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build the will 6
projects shortlisted for regional or
national awards
1regional award
7projects being written up for
publication with BMJ
6teams presenting their
work to the Trust board each year
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
1 How would you rate the will to undertake a QI programme in your organisation
2 What are the barriers stopping you from undertaking this work
3 In light of what you heard today will you be doing anything differently in order to make a case for change
Building the Will
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020Build
improvement capability
Face to face improvement training -hundreds of staff services users Governors to be trained over the next few years
Support for improvement work from the Trustrsquos QI
team
IHI Open School available to all
Strategic partnership with IHI
Boardsessions
ELFT_QI
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Experts
Front line staff
Clinical leaders
Directorate improvement
leads
Board
Estimated number = 3300Requirement = introduction to quality improvement identifying problems change ideas testing and measuring
changeTime-frame = train 10-20 in 2 years
Estimated number = 250Requirement = deeper understanding
of improvement methodology measurement and using data leading
teams in QITime-frame = train 30-50 in 2 years
Estimated number = 30Requirement = deeper understanding
of improvement methodology understanding variation coaching
teams and individualsTime-frame = train 100 in 2 years
Estimated number = 10Requirement = setting direction and
big goals executive leadership oversight of improvement being a
champion understanding variation to lead
Time-frame = train 100 in 2 years
Estimated number = 5Requirement = deep statistical process control deep improvement methods effective plans for implementation amp
spreadTime-frame = train 100 in 2 years
Where are we
On track to train over 500 people through 5 six-month waves of learning between
2014-16 First 3 waves delivered with the IHI
On track All senior staff being encouraged to join QI training
over next 2 years
New need recognised Developing improvement
coaches programme will train 30 QI coaches in 2015
On track Most Executives will have undertaken the ISIA and
Board training has been delivered in 2015
Currently have 3 improvement advisors with 15wte deployed
to QI Will need to build more capacity
at this level
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Build
improvement capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
1100Open School lessons completed
Build improvement
capability
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Build improvement
capability
Recruited a central QI team
Board sessions
Developed 3 improvement advisors
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Coaching teams from the very start
Success
Form a team
Agree the quality
issue to be tackled
Ensure patient
(and carer) involvement
Find time to meet
ELFT_QI
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Workshop
(3 days)
Webex 2Webex 1
bull Faculty consultsbull Webex callsbull Coaching calls
Webex 3 Learning Set 2 amp graduationAP-5AP-4
The two learning sets will be focused on sharing the participantsrsquo work on their projects and learning from each other These sessions also will reinforce the content
from the Webex calls and the ISIA workshop
Learning set 1
ELFT_QILearning and coaching over 6 months
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
1 What improvement capability exists in your organisation
2 How could you shuffle existing resources to create some capacity to start improvement work
3 How would you build a business case and convince your leadership team about the need to invest in building capability and capacity for improvement
Building Capability
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
Alignment
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
1 What would you have to change to produce alignment in your organisation
2 How do you look at data and talk about improvement and safety at every level
3 What can you change stop or review to create space for improvement What are the structures in place to support improvement
Alignment
Table Discussion
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
How have our projects developed
over time
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
September 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
October 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
November 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
December 2014
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
January 2015
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
AIMTo provide the highest
quality mental health and community
care in England by
2020
QI Projects
February 2015
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Right Care Right Place Right Time
TH CollaborativeRoman Globe Bricklane Lea Millharbour Rosebank
MHCOPLarch Lodge Cedar Lodge Sally Sherman Ward
CHNEPCS Teams (North East North
West Central South)Multiple IP Wards
CampHRehab AOS Connolly Bevan
NewhamMultiple IP wards
NewhamPsychology
MHCOPTraining Lodge
ChildrenrsquosCDC x2
CAMHS x3
MHCOPMemory Service
CampHAll CMHTS
ForensicsClerkenwell
REDUCE HARM BY 30 EVERY
YEAR
RIGHT CARE RIGHT PLACE RIGHT TIME
VIOLENCE REDUCTION
PHYSICAL HEALTH
ACCESSPRESSURE
ULCERS
ELFT_QI
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Is it making a difference
ELFT_QI
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
50
925
135
1775
220
2625
De
c 1
6
Ja
n 1
7
Feb
17
Ma
r 1
7
Ap
r 1
7
Ma
y 1
7
Ju
n 1
7
Ju
l 1
7
Au
g 1
7
Se
pt 1
7
Oct 1
7
No
v 1
7
De
c 1
7
Jan 1
8
Feb
18
Ma
r 1
8
Ap
r 1
8
Ma
y 1
8
Ju
n 1
8
Ju
l 1
8
Au
g 1
8
Se
pt 1
8
Oct 1
8
No
v 1
8
De
c 1
8
Ja
n 1
9
Feb
19
Incid
en
ts e
ach
mo
nth
Month
Incidents of physical violence across the Trust (C Chart)
179 per month
145 per month
19 reduction across the TrustDatix incident reporting
ELFT_QI
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
10
325
55
775
100
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f R
estr
ain
tsEpisodes of Restraint in Prone Position - C Chart
50
825
115
1475
180
Jan-1
6
Feb
-16
Ma
r-1
6
Apr-
16
Ma
y-1
6
Jun-1
6
Jul-1
6
Aug-1
6
Sept-
16
Oct-
16
No
v-1
6
De
c-1
6
Jan-1
7
Feb
-17
Ma
r-1
7
Apr-
17
Ma
y-1
7
Jun-1
7
Jul-1
7
Aug-1
7
Sept-
17
Oct-
17
No
v-1
7
De
c-1
7
Jan-1
8
Feb
-18
Ma
r-1
8
Apr-
18
Ma
y-1
8
Jun-1
8
Jul-1
8
Aug-1
8
Sept-
18
Oct-
18
No
v-1
8
De
c-1
8
Jan-1
9
No
o
f In
cid
en
ts
Incidents resulting in the use of Restraint (C Chart)
68 per month
30 per month
56 reduction
134 per month112 per month
16 reduction
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
BU
ILD
ING
WIL
L
Build a broad coalition for
change
Take time to bring people with you
Shift decision-making to the edge
Develop a compelling narrative
Find some clear signals of change
Use the power of stories
Take every opportunity to
celebrate
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
BU
ILD
ING
CA
PA
BIL
ITY
amp
CA
PA
CIT
Y
Be prepared to invest
Train all levels and across disciplines
Realign existing resources
Stop lower value work
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
ALI
GN
MEN
T amp
IN
TEG
RA
TIO
N
Start at the topCreate a support
structure
Build a learning system
Ensure patients and carers are
integral
Ensure the context is ripe
Line of sight from team to system
goals
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Organisational culture is created by what leaders pay attention tohellip
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
web qielftnhsuk
email qielftnhsuk
ELFT_QI
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
lsquoIt is a long causal link from a leaderrsquos actions to outcomesrsquo
(Oslashvretveit 2008)
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
WHAT IS LEADERSHIP FOR HEALTHCARE IMPROVEMENT
ldquoIt therefore seems that leaders are able directly to affect the safety of
their teamsrsquo actions and outcomes -an extremely important finding for
patient carerdquo(Firth-Cozens and Mowbray 2001)
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
The FMLM Value Chain
FMLM Adaptation of the Sears Value-Profit Chain
Sears a North American departmentstore was suffering heavy financiallosses it successfully implementedtraditional turn-around but recognisedthat sustainability relied on committedand engaged staff The model showsthat committed and engaged staffmeasurably serve the customer better
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Hospitals with greatest clinician involvement in management score 50 higher on key measures of organisational performance
McKinsey Quarterly 2008
In attempted service improvement organisations with strong clinical leadership are more successful
NHS SDO 2006 Managing Change and Role Enactment in Clinical Leadership
High performing NHS Trusts have CEOs with a collaborative style that engages clinicians
Academy of Royal Medical Colleges NHS Institute 2007
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
ldquoUltimately the more engaged staff members are the better the
outcomes for patients and the organisation generallyrdquo
West and Dawson Employee Engagement and NHS Performance (Kings Fund) 2013
ldquopatient experience improves inspection scores are higher and infection and mortality rates are
lowerrdquo
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Leadership for Improvement is
Culturally sensitive Culture plays an important role in QI and leadership and culture are inter-dependent
Inclusive It is linked less with striving to know all the answers and more with engaging others to make their personal contribution
Team-based It has a direct impact on teams and their ability to improve the quality of what they do
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Leadership for Improvement is
Personal The significance of personal style and preference has an undeniable impact
Collective To become embedded in the culture the focus is on groups of individuals creating collective effort
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
The Annual NHS Staff Survey
There has been an annual staff survey in the English NHSsince 2003 and questions on engagement wereintroduced in 2009
It is measurespsychological engagementadvocacy andinvolvement
lsquoI look forward to going to workrsquolsquoI am enthusiastic about my jobrsquolsquotime passes quicklyrsquo
lsquowould I (an employee) recommend my organisation as a place to work and be treatedrsquo
lsquoI am able to make suggestions to improve the work of my teamrsquolsquothere are frequent opportunities for me to show initiativersquolsquoI am able to make improvements happenrsquo
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
ENGAGEMENT AND RELATIONSHIP SKILLS ARE FUNDAMENTALLY IMPORTANT IN LEADING IMPROVEMENT
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Engaging others to improve healthcare - IHI
discovering common purpose such as improving outcomes and efficiency
reframing values to make doctors partners in not customers of the organisation and promoting individual responsibility for quality
fine-tuning engagement to reach different types of staff ndash identifying and encouraging champions educating leaders developing project management skills and working with laggards
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Engaging others to improve healthcare - IHI
using improvement methods such as performance data in a way which encourages buy-in rather than resistance
supporting clinical leaders all the way to the board
involving doctors from the beginning ndash working with leaders and early adopters choosing messages and messengers carefully making doctor involvement visible communicating candidly and often and valuing doctorsrsquo time by giving management time to them
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Getting (and keeping) engagement
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
lsquoLet whoever is in charge keep this simple question in her head (not
how can Ialways do this right thing myself
but) how can I provide for this right thing to always be
donersquo
Florence Nightingale (1969)
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
How FMLM can help
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
THANK YOU
For the latest FMLM QI updates nikkikf FMLM_UK FMLMQI wwwfmlmacukquality-improvement enquiriesfmlmacuk
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Round 2
Same taskSecond PDSA
What can you change to improve speedWhat is your prediction for impact
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Evaluating Quality Improvement
Rob Bethune robbethune
for the non-researcher
(like me)
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
The Plan
bull Small scale
ndash Questionnaire (including culture surveys)
ndash Interviews
bull Kirkpatrick Framework
bull Routine Collected Administrative Data
bull Large scale
ndash Culture Surveys
ndash Triangulation of quantitative and qualitative
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Typical Example
bull lsquoI would feel safe being treated here as a patientrsquo
ndash Agree
bull Strongly 5
bull Slightly 4
ndash Neutral 3
bull Slightly 2
bull Strongly 1
ndash Disagree
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Results by hospital (1-14) lsquoI would feel safe being treated here as a patientrsquo
(5 is agree strongly 3 neutral and 1 disagree strongly)
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Because safety culture is correlated to clinical outcome
bull Barach P Johnson JK Ahmad A Galvan C Bognar A Duncan R et al A prospective observational study of human factors adverse events and patient outcomes in surgery for pediatric cardiac disease J Thorac Cardiovasc Surg 2008 Dec136(6)1422-8
bull Bonner AF Castle NG Men A Handler SM Certified nursing assistants perceptions of nursing home patient safety culture is there a relationship to clinical outcomes J Am Med Dir Assoc 2009 Jan10(1)11-20
bull Donnelly LF Dickerson JM Goodfriend MA Muething SE Improving patient safety effects of a safety program on performance and culture in a department of radiology AJR Am J Roentgenol 2009 Jul193(1)165-71
bull Mardon RE Khanna K Sorra J Dyer N Famolaro T Exploring relationships between hospital patient safety culture and adverse events J Patient Saf 2010 Dec6(4)226-32
bull Kline TJ Willness C Ghali WA Determinants of adverse events in hospitals--the potential role of patient safety culture J Healthc Qual 2008 Jan-Feb30(1)11-7
bull Haynes AB Weiser TG Berry WR Lipsitz SR Breizat AH Dellinger EP et al A surgical safety checklist to reduce morbidity and mortality in a global population N Engl J Med 2009 Jan 29360(5)491-9
bull Pronovost PJ Berenholtz SM Goeschel C Thom I Watson SR Holzmueller CG et al Improving patient safety in intensive care units in Michigan J CritCare 2008 Jun23(2)207-21
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Designing your own questionnaire
bull lsquoExpertsrsquo come up with the questions
bull Trial with potential participants
bull Adjust
bull Check validity
bull Adjust
bull Do statistics for internal validity
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Strongly
disagreeDisagree
Neither
disagree
nor agree
AgreeStrongly
agree
At this stage in my career it is
important to have basic
training in quality
improvement
I have a role in contributing to
the scientific evidence behind
patient care
I would only feel confident
improving patient care with
senior help
If I had an improvement idea I
would have the skills to
execute the project
If I had an improvement idea I
would know who to approach
in my Trust
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Qualitative Interviews
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Kirkpatrick Framework (for QI)
bull 1) Experience
bull 2) Learning (did they start using QI methods)
bull 3) Process (did they work differently)
bull 4) Outcome (did the organisation improve)
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Routine collected quantitative data
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Two recent studies ndash ACS NSQIP
bull Association of Hospital Participation in a Quality Reporting Program With Surgical Outcomes and Expenditures for Medicare Beneficiaries Nicholas H Osborne MD MS12 Lauren H Nicholas PhD3 Andrew M Ryan PhD14 JyothiR Thumma MPH1 Justin B Dimick MD MPH14 JAMA 3rd Feb 2015313(5)496-504 doi101001jama201525
bull Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time Evaluation of Hospital Cohorts With up to 8 Years of Participation Cohen ME1 Liu Y Ko CY Hall BL Ann Surg2015 Feb 26
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Routine collected quantitative data
Use it with extreme caution
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
PiCES Evaluation(Patient safety collaborative
evaluation study)
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Qualitative
Culture Surveys
Routine Collected Data
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Lessons I have Learnt
bull Try and plan in advance
bull Get advice from researchers
bull Try and get funding
bull Look to evaluation as a formative tool
bull Actually proving that you have made a wider difference is very very hard and might not be worth the effort
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Any questions
BMJQuality
qualitybmjcom
Discussion
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Thank you
Round 3
The excitement builds
What can you change to improve the pace
Round 3
The excitement builds
What can you change to improve the pace
