Embed Size (px)
Citation preview
2
Contents Background 3QualityImprovementvsaudit 4Modelforimprovement 4PDSAcycles 4Exploringtheproblem 5SMARTaims 6Driverdiagrams 7Measurements 8Runcharts 9Psychologyofchange 10ARCPCriteria 10Furtherresources 11
SPITlost3kginjustonebooklet!
Before After
3
BackgroundTheimportanceofjuniordoctorswithintheNHScannotbeunderestimated;thisisrecognisedbymanyinfluentialpeopleandorganisationssuchastheGMC.SirRobertFrancisdescribesusas“theeyesandears”oftheHealthService,beingthegroupmostlikelytoencountershortfallsinthesystem.Withthisinmind,howdowethenaddresstheseshortfalls?TraineesImprovingPatientSafety(TIPS)throughQualityImprovement(QI)wasdevelopedtoincreaseunderstandingofQImethodologyamongstjuniordoctorstobetterpreparethemtotacklethechallengestheyarelikelytofaceintheirclinicalroles.Improvementisascience.W.EdwardsDemingiscreditedasoneoftheforefathersofQI.Originallyanelectricalengineer,hisstructuredworkonstatisticsandImprovementledtothedesignofPDSAcyclesandhisLensofProfoundKnowledge(LOPK).TheLOPKiscomprisedoffourdifferentcomponentsor‘lenses.’Allfouroftheseshouldbeconsideredandaddressedinordertoobtainthebestresultsfromanimprovementproject.
1. AppreciationofSystems–Understandingtheprocesseswithinasystem/environment.2. HumanPsychology–howhumannatureandbehaviourcanaffectthesystem3. UnderstandingVariation–Havinganawarenessof‘normal’vs.‘notnormal’variation.4. TheoryofKnowledge–Knowledgeandthelimitationsofwhatcanbeknown.
Systems
Psychology
Variation
Theory
4
QIvsAuditQIdiffersfromauditaprocessmorefamiliartomedicalpersonnelandisbeingusedmoreandmorefrequentlyasatooltodevelopthehealthservice.IntheFoundationProgrammeyoumustnowundertakeaQIprojectbytheendofFY2.Thisdoesnothavetohavebeenasuccessfulproject.Wecanlearnjustasmuchfromanunsuccessfulproject–asleastwenowknowwhatdoesn’twork. Audit QualityImprovement
Purpose Tomeasurecurrentpracticeagainstastandard
Tobringnewknowledgeandimprovementintopractice
Measurement Againstastandard DemonstrateImprovementthroughoutcomes
Data Sufficienttorepresentpractice Gather“justenough”toinformnextPDSAcycle
Time Auditcycles(months) Quickrapidtestsofchange(weeks)
QIdoesnotrelyoncomparisontoastandard.DatacollectionforQItendstobelessresourceandtimeintensiveasthekeyfocusisoncheckingforimprovement,ratherthangatheringallavailableinformationforjudgement.Asaresultofthis,itispossibletotestandmeasuremultiplechangesinarelativelyshortspaceoftime.TheModelforImprovement(MFI)actsasausefultooltostructureimprovementwork.TheModelforImprovementFirstintroducedbytheAssociatesforProcessImprovement(API),theModelforImprovementcomprisesoftwodifferentparts;threequestionsandthePDSA(Plan-Do-Study-Act)cycle.
PDSACycles
Step1:Plan• Statetheaimoftheproject• Developaplantotestthechangeincludingmeasures• MakeapredictionaboutwhatwillhappenandwhyStep2:Do• Carryoutyourintervention• Startcollectingandmeasuringdata• DocumentproblemsandunexpectedobservationsStep3:Study• Analyseyourdata• Comparewithyourpredictions• ReflectandsummarizeanylearningStep4:Act• Determinenextsteps.Shouldyouadopt,adoptorabandon?• Prepareaplanforthenexttest.
5
Step1:Question:Whatarewetryingtoaccomplish?Itmayseemlikecommonsense,butthefirstthingthatshouldhappenwithanyimprovementprojectistoclearlydefinetheproblemthatrequiressolving.It’sthenimportanttothinkaboutwhyyourproblemisactuallyaproblem.ExploringtheProblemAgoodstartingpointistoconsiderthisfromdifferentperspectives.Inahospitalenvironment,thiscouldbe:
• Yourself• Yourteammembers• Otherwardstaff• Thedepartment• Thehospital/organisationasawhole.
Bydoingthis,youstarttogainevidencethatcanbearticulatedtootherstobuildwillforchangeandcreatebuy-in.Followingthis,youthenneedtoconsiderwhatitisthatyouaretryingtoachievefromidentifyingaproblem.
Problem:obesity
Myself:causesmyshortnessofbreath,earlyOA,painandreducedmobility
Familymembers:Can’tplaysportswithmychildren,can’tgooutwithfamily
NHS:Attendingmultipleappointments,requiremedication,bariatricsurgery
Problem:unnecessaryantibioticprescribinginchildrenwithURTI
Us:busyinnercitypractice,parentalpressures,notmeetingNICEguidelines
Public:Increasedantimicrobialresistance
NHS:Increaseduseofmorepotentandmoreexpensiveantibiotics
6
CreatingSMARTaimsAspreviouslyindicated,improvementrequiresclearandrelevantgoalsinorderforittobemostsuccessful.OneeffectivewayofconstructingthisistouseaSMARTaim.
Specific What exactly are you trying to achieve? (Be specific about the subject of your
aim!)
Measurable
What is the outcome you will be measuring? (Include a number/percentage in your aim)
Achievable
Does your team have the potential to do this?
Realistic
Does your team have the time/resources to be able to do this?
Timely
When will you achieve your outcome by? (Include a date/time in your aim!)
Step2:Question:Whatchangescanwemakethatwillresultinanimprovement?
Whatneedstohappeninorderforouraimtobemet? Howarewegoingtomeasurethechange?
Achangeconceptisageneralnotionorapproachtochangethathasbeenfoundtobeusefulindevelopingspecificideasforchangesthatleadtoimprovement.Creativelycombiningthesechangeconceptswithknowledgeaboutspecificsubjectscanhelpgenerateideasfortestsofchange.Aftergeneratingideas,Plan-Do-Study-Act(PDSA)cyclesareusedtotestachangeorgroupofchangesonasmallscaletoseeiftheyresultinimprovement.Iftheydo,thetestsshouldbescaleduptograduallyincorporatelargerandlargersamplesuntilyouareconfidentthatthechangesshouldbeadoptedmorewidely.Wecanorganiseourtestsofchangeusingadriverdiagram.TheyprovidealogicalwaytoidentifyoutcomesneededtomeetanaimandIdentifykeyinterventionstomeettheseoutcomesTheseconsistofprimarydrivers:Keyelementswithoutwhichwewouldnotmeetouraim.Secondarydriversarethingsthatneedtohappentoensureourprimarydriversaremet.Theseoftenendupformingchangeideas.
SMARTAim:
Lose3kginbodyweightby31stSeptember2017
SMARTAim:
Toreduceinappropriateantibioticprescribing(inthisGPpractice)forsorethroatandearpaininunder16’sby50%March2014
7
8
Step3:Question:Howwillweknowthatachangeisanimprovement?Ashighlightedpreviously,measurementforimprovementdifferstomeasurementforaudit.Weneedtoknowthatthechangewehavemadehasdirectlyresultedinanimprovementandthattheimprovementisn’taresultofotherfactorsWethereforehavetothinkaboutoutcome,processandbalancingmeasuresTypesofMeasuresinImprovementTherearethreetimesofmeasuresinatypicalimprovementproject.Thebelowexamplescouldbeusedifyouweretryingtoloseweight.OutcomemeasuresAnoutcomemeasureiswhatyoumeasuretofindoutwhetheryouareoraren’tmeetingyouraime.gnumberofpoundsweightloss
ProcessmeasuresAprocessmeasureistheretoensureyourchangeideaorinterventionisbeingtested
BalancingMeasuresTheseconsidertheeffectofyourinterventionsonotherpartsofthesystem
Weightlossinkg
Numberoftimesexercisedperweek
Numberofcaloriesconsumed
Amountofextramoneyspent(gymmembership,pre-workout,healthyfoodprep)
Numberofsocialeventsturneddown
Percentageofunder16sinappropriatelyprescribedantibiotics
Percentageofstaffgiventraining
Percentageofcomputerswithguidelinesonthedesktop
Patientsatisfactionscore(friendsandfamilytest)
Amountofclinicaltimelostduetotraining
9
RunChartsWeuserunchartstomeasuredataovertimeandeasilydetecttheimpactofchangesonthesystem.Runchartsenableustounderstandthecommonvariationinthesystemandidentifywheresomethinghashappenedoutsidethesystemi.eanastronomicalpoint(redcircle).
10
PsychologyofChange/ImprovementAkeyelementofanyimprovementprojectisengagingthestakeholders.Wecandefineastakeholderasanyonewhohasaninterest,concernorisimpactedbytheproject.Wecanuseamatrixasbelowtoconsiderthemostusefulapproachtotakewitheachgroupofstakeholders.Wedothisbylistingallstakeholdersandthensortingthemintowheretheycurrentlysitandconsideringwhethertheyareinthebestplacefortheadvancementoftheproject.Forexampleitmaybeusefultoconsiderstrategiesformovingastakeholderfromthetoplefthandboxintothetoprighthandbox.
Somethingtoremember:Yourprojectneedstobeabletorunwithoutyouinit–sothinkaboutthisfromthebeginning.Howwillthisbesustainable?ARCPCriteriaAllprojectsmusthave:
- ASMARTAim- Measurement(ideallybothanoutcomeandprocessmeasure)- RunChart(Datadisplayedovertime)
Optionalbutdesirable:
- Processmap- DriverDiagrams- Balancingmeasures- DocumentationsofPDSAcycle- OthertoolsforimprovementnottaughtbyTIPS–rootcauseanalysis,fishbone,%why’s.
11
Furtherresourcesandopportunitiestoshowcasework:
- NHSImprovement- BMJQuality–publishyourQIproject- BMJLearning- NHSScotland- YorkshireandHumberImprovementAcademy- FacultyMedicalLeadershipandManagement- NorthWestLeadershipSchool(conference15thJuneattheAJBellstadium,Manchester.)
@HSEQI@LeicsMedQI@HEFTQCP@QIFUNdamentals
@IHIOpenSchool@TheIHI@QIWEAHSN@QuID_UK
Getintouchwithifyouneedhelpandadvice
@TIPSQI1
