Embedding a Culture of Continuous Quality
ImprovementImprovement
27th October 2001
Quality Improvement Hub
• Share progress on development of NHS Scotland's Quality Improvement Hub.
• Opportunity to share your boards approach to the development of local quality
improvement plans – (QUEST funding)
• Hub role in supporting building of capacity and capability in Quality Improvement
– input into the development
Session Aims
– input into the development
• To build a national picture of where boards are in terms of co-ordinating for quality
improvement in their local contexts, and to discuss and generate ideas and agree
next steps.
• Bringing together quality improvement leads from all boards in a key networking
environment, and further develop the community of quality improvement leads
and the directory of quality improvement practitioners.
• To explore how the national Quality Improvement Hub can support boards with
the implementation of the Healthcare Quality Strategy and the NHS Scotland
Productivity and Efficiency Framework.
Quality Improvement Hub
09:30 Coffee and Registration Jane Murkin
10:00 Welcome, Introduction and Aims Jane Murkin
10:10 Building Capacity and Capability for
Sustainable Quality Improvement – Can we
do it?
Jason Leitch
Agenda
do it?
11:10 NHSScotland’s Quality Improvement Hub Jane Murkin/Shona Cowan
11:30 Break – Tea and Coffee Available
11:45 Local Board’s Approach to Co-ordinating for
Quality Improvement
• NHS Lanarkshire experience
• NHS Tayside’s experience
Pam Milliken
Carrie Marr
12:15 Questions and Discussion
12:45 Lunch
Quality Improvement Hub
1:30 Group Discussions
Small group discussions around:• Implementation support
• Building capacity and capability
Jane Murkin & Harriet Hunter
Jane Murkin
Agenda Continued
• Building capacity and capability
• Data and measurement for improvement
• Finding and Sharing knowledge
Shona Cowan & Suzanne Graeme
Roger Black & Harriet Hunter
Ann Wales & Annette Thain
3:30 Feedback from discussions
3:45 Next Steps Jane Murkin
4:00 Close
Building Capacity and Capability for Sustainable
Quality Improvement – Can Quality Improvement – Can we do it?
Why is it urgent and why we must work together.
Photos are displayed with the kind permission of Mrs. Clarke and her family
The Healthcare Quality Strategy for Scotland
• Person-Centred - Mutually beneficial partnerships
between patients, their families, and those delivering
healthcare services which respect individual needs and
values, and which demonstrate compassion, continuity, clear
communication, and shared decision making.
• Effective - The most appropriate treatments, interventions, • Effective - The most appropriate treatments, interventions,
support, and services will be provided at the right time to
everyone who will benefit, and wasteful or harmful variation
will be eradicated.
• Safe - There will be no avoidable injury or harm to patients
from healthcare they receive, and an appropriate clean and
safe environment will be provided for the delivery of
healthcare services at all times.
6 Quality Outcomes
1. People have the best start in life and are enabled to live longer healthier lives
2. People are supported to live well at home or in the community
3. Everyone has a positive experience of healthcare
4. All staff feel supported and engaged4. All staff feel supported and engaged
5. Healthcare is safe for every person, every time
6. Best possible use is made of available resources
Presumptions
Expertise
Excellence
Motives
“Conquering the world on horseback is easy: it is dismounting and governing that is hard”
Genghis Khan
Central line infection rate (per thousand line days)
6
8
10
12
March 2011:zero central line infections
in whole country
0
2
4
6
Jan-
08A
pr-0
8Ju
l-08
Oct
-08
Jan-
09A
pr-0
9Ju
l-09
Oct
-09
Jan-
10A
pr-1
0Ju
l-10
Oct
-10
Jan-
11A
pr-1
1Ju
l-11
NHS Lothian adverse event rate
Rate of Adverse Events per 1000 patient days(as at August 2011)
52
50
60
70
80
AE
s p
er
10
00 p
ati
en
t D
ays
RIE, WGH & SJH Rate of Adverse Events per 1000 patient days(as at August 2011)
52
50
60
70
80
AE
s p
er
10
00 p
ati
en
t D
ays
RIE, WGH & SJH Rate of Adverse Events per 1000 patient days(as at August 2011)
52
50
60
70
80
AE
s p
er
10
00 p
ati
en
t D
ays
RIE, WGH & SJH
0
10
20
30
40
Nov-0
8
Dec-0
8
Ja
n-0
9
Fe
b-0
9
Mar-
09
Apr-
09
May-0
9
Ju
n-0
9
Jul-09
Au
g-0
9
Se
p-0
9
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Fe
b-1
0
Mar-
10
Apr-
10
May-1
0
Ju
n-1
0
Jul-10
Au
g-1
0
Se
p-1
0
Oct-
10
Month of Discharge
AE
s p
er
10
00 p
ati
en
t D
ays
8 data points below current median
= a shift in the data. New process
median provisionally 30 per 1000.
This is a 42% reduction from
30
0
10
20
30
40
Nov-0
8
Dec-0
8
Ja
n-0
9
Fe
b-0
9
Mar-
09
Apr-
09
May-0
9
Ju
n-0
9
Jul-09
Au
g-0
9
Se
p-0
9
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Fe
b-1
0
Mar-
10
Apr-
10
May-1
0
Ju
n-1
0
Jul-10
Au
g-1
0
Se
p-1
0
Oct-
10
Month of Discharge
AE
s p
er
10
00 p
ati
en
t D
ays
8 data points below current median
= a shift in the data. New process
median provisionally 30 per 1000.
This is a 42% reduction from 0
10
20
30
40
Nov-0
8
Dec-0
8
Ja
n-0
9
Fe
b-0
9
Mar-
09
Apr-
09
May-0
9
Ju
n-0
9
Jul-09
Au
g-0
9
Se
p-0
9
Oct-
09
Nov-0
9
Dec-0
9
Ja
n-1
0
Fe
b-1
0
Mar-
10
Apr-
10
May-1
0
Ju
n-1
0
Jul-10
Au
g-1
0
Se
p-1
0
Oct-
10
Month of Discharge
AE
s p
er
10
00 p
ati
en
t D
ays
8 data points below current median
= a shift in the data. New process
median provisionally 30 per 1000.
This is a 42% reduction from
30
43% reduction
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)
Conclusion: The “Defect Rate” in the technical quality of American health care is
45%approximately 45%
Projected Scottish Government spending
26,000
28,000
30,000
32,000
£ M
illio
ns (
20
10
-11
Pri
ce
s)
2009-10 2025-2616 years
£42 billion
20,000
22,000
24,000
26,000
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
2014
/15
2015
/16
2016
/17
2017
/18
2018
/19
2019
/20
2020
/21
2021
/22
2022
/23
2023
/24
2024
/25
2025
/26
2026
/27
£ M
illio
ns (
20
10
-11
Pri
ce
s)
-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
-70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70
Improvement work?
© 2010 Institute for Healthcare Improvement
The “Quality Curve”Shift and narrow the curve:What is the norm?
2
Cut the tail:What is unacceptable?
Extend the ambition: What is great? (What is possible?)
1 3
What does it mean to Build Capacity & Capability for Quality Improvement?
• Having the word “Quality” appear frequently in your Mission, Values and Philosophy statements?
• Developing a compelling Quality Slogan?
• Assigning someone to be the Director of Quality Improvement?
© 2010 Institute for Healthcare Improvement
• Applying for a local or national quality award?
• Being recognized as a top performer in a public database?
• Directing all employees to read Deming’s Out of the Crisis?
• Creating a dashboard of quality and safety measures?
• Attending Learning Session 3?
Key TermsCapacity
• The ability to receive, hold or absorb
• The maximum or optimum amount of production
• The ability to learn or retain information.”
• The power, ability, or possibility of doing something or performing
• A measure of volume; the maximum amount that can be held
© 2010 Institute for Healthcare Improvement
Capability• The power or ability to generate an outcome
• The ability to execute a specified course of action
• The sum of expertise and capacity
• Knowledge, skill, ability, or characteristic associated with desirable
performance on a job, such as problem solving, analytical
thinking, or leadership
• Some definitions of capability include motives, beliefs, and values
00.5
11.5
22.5
3
Jan-0
8
May-
08
Sep-0
8
Jan-0
9
May-
09
Sep-0
9
Jan-1
0
May-
10
SPSP c. Diff Rate (c. Diff s per 1000 patient days)
Key Terms: Helen Bevan
Capacity – having the right number and level of people who are actively engaged and able to take action.
© 2010 Institute for Healthcare Improvement
Capability – the people have the confidence and the knowledge and skills to lead the change.
Helen Beven, “How can we build skills to transform the healthcare system?”
Journal of Research in Nursing 15(2) 139-148, 2010.
To build a sustainable infrastructure that produces highly reliable QI excellence
by (fill in the date).
The Capacity and Capability Aim
© 2010 Institute for Healthcare Improvement
by (fill in the date).
How good? By when?
Capacity Building Issue Current Status Future Priority
C IP NS H M L
1. Evaluating your organization's mission,
vision and values to make sure that they
are consistent with QI principles.
2. Educating the following groups in the
theory and tools of QI:
• The Board
• Senior leaders
• Managers
• Clinicians
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
For each item, you should make two
responses. First, indicate the
Current Status of each item within
your organisation by marking one of
the following responses:
Completed (C)
In Process (IP)
Not Started (NS)
Exercise #1Building Capacity Self-Assessment©
© 2010 Institute for Healthcare Improvement
• Clinicians
• Staff
____
____
____
____
____
____
____
____
____
____
____
____
3. Restructuring your performance evaluation
system so that it supports your efforts in
quality improvement.
4. Working with suppliers to establish long-
term partnerships that are based on
collaborative efforts to improve quality.
5. Providing employees with the support and
resources they need to participate in QI teams
and work.
6. Setting up process improvement teams.
7. Creating a process to set priorities for
selecting quality improvement initiatives.
8. Developing performance indicators of
quality improvement initiatives.
9. Preparing communication tools that share
information on quality goals and initiatives
with all stakeholders.
Not Started (NS)
Then, assign what you believe will
be your Priority for each item over
the coming twelve months by
marking one of the following
responses:
High (H)
Moderate (M)
Low Priority (L)
Source: R. Lloyd. Quality Health Care: A Guide to
Developing and Using Indicators. Jones & Bartlett
Publishers, Sudbury, MA, 2004.
A Few Key Questions about Building Capacity and Capability
• Will you involve everyone or just a few targeted groups?
• What is your sequence for development and deployment?
• What methods do you plan to use to build capacity and
© 2010 Institute for Healthcare Improvement
• What methods do you plan to use to build capacity and capability?
• Do you have a model or framework to guide your journey?
• How will you make sure all this “sticks?”
Adapted and expanded from a conversation with Tom Nolan, Associates in Process Improvement on material he presented at the IHI Strategic Partners Roundtable, April 17-18, 2006.
Who needs to be developed?
Governance?Executives?Managers?
Supervisors?
© 2010 Institute for Healthcare Improvement
Supervisors?Front Line Workers?
Improvement Advisors (IAs)?
Adapted from Tom Nolan, Associates in Process Improvement presented at the IHI Strategic Partners Roundtable, April 17-18, 2006
√
How many quality expertsdo we need?
Two suggestions for determining this number:
Number of employees
© 2010 Institute for Healthcare Improvement
√ employees
Or…consider that no employee should be more than 2 steps (individuals)
away from a QI expert.
Two steps from an ‘expert improver”
Which way does (should)capacity and capability building flow?
Top Down?
Macrosystem
Details on the Microsystem can be found in:Quality by Design: A Microsystems Approach.
By E. Nelson, P. Batalden and M. Godfrey. Jossey-Bass, 2007.
© 2010 Institute for Healthcare ImprovementBottom Up?
Spread from the Middle?
Mesosystem
Microsystem
Kaiser Permanente’s System for
Performance Improvement
Alide Chase SVP, Care and Service Quality
Lisa Schilling, RN MPH, VP, Healthcare Performance Improvement
Our system is based on the attributes of high performing organizations
Best quality
KP needs to build capability in these six areas
in order to achieve breakthrough performance
32© Kaiser Permanente 2010 reproduce by permission only
Best serviceMost affordableBest place to
work
Experts Operational
Leaders
ChangeAgents
Everyone
(Staff, Supervisors,
Many People Few People
A key operating assumption of
building capacity is that different groups of people will have different levels of
need for PI knowledge and skill.
Content: What Skills Do We Need?
33© Kaiser Permanente 2010 reproduce by permission only
Experts Leaders (Executives)
(Middle Managers, Stewards,
project leads)
Supervisors,UBT lead
triad)
Continuum of PI Knowledge and Skills
Deep Knowledge
Our approach will be to make sure that each group receives the knowledge and skill sets they need
when they need them and in the
appropriate amounts.
SharedKnowledge
BUILDING IMPROVEMENT CAPABILITYCAPABILITY
Uma Kotagal, MBBS, MSc
Sr. Vice President
Quality And Transformation
Capability vs Capacity
• Improvement Capability – An individual’s knowledge & skill to design improvement
initiatives to achieve measurable results & the ability to execute (i.e. develop, test, measure & implement changes)
improvement efforts & sustain results.improvement efforts & sustain results.
• Improvement Capacity– An organization’s resources which enable it to initiate &
sustain a transformation effort. This includes capable individuals but also structures, processes, infrastructure including quality experts & measurement experts.
Leadership Topics
• Business Case for Quality
• Transformational leadership
• Chronic care improvement
• Managing a portfolio of projects
• Implementation & sustaining
• Patient safety
• Research & improvement
Faculty Development
AimTo provide a pathway for interested faculty to develop knowledge & skills to publish advanced QI studies, engage in QI research & lead organization-wide QI
transformation efforts.transformation efforts.
CCHMC Interventions– Advanced Improvement Methods (AIM)
– Quality Scholars Program
Exercise #2Who needs what? (The Dosing Formula)
This Exercise is designed to create a dialogue on what we call the “dosing
formula.” That is, which groups of individuals within your organization need to have what levels of knowledge and skill to successfully build a sustainable
infrastructure that produces highly reliable QI excellence?
The worksheet on the next page provides a list of Skills & Knowledge (the rows)
associated with organizations that have demonstrated QI excellence. For each of
© 2010 Institute for Healthcare Improvement
the listed Skills & Knowledge items indicate the level or “dose” of Skill &
Knowledge you think each group (the columns) needs using the following
response scale:
1 = They need to know the basic terms, concepts and methods when they hear them2 = They need to be able to explain the terms, concepts and methods to others3 = They need to be able to teach the terms, concepts and methods to others4 = They need to be seen as an organizational lead and champion for the terms,
concepts and methods
Exercise #2Who needs what? (The Dosing Formula)
Skills & Knowledge
Non-Execs Execs Senior clinicians
(doctors and nurses)
Middle Management, Directors & Supervisors
Frontline Staff
(clinical and non-clinical)
QI Experts
(IAs)
Models for QI (theory &
concepts)
Leadership for
© 2010 Institute for Healthcare Improvement
39
Leadership for
improvement & cultural
transformation
Teamwork and
Facilitation
Gathering information
Analyzing and
interpreting data
Presentation skills
Understanding variation
QI tools and methods
Change management
Patient-centered care
The Primary Drivers of Capacity & Capability Building
Will
Having the Will (desire) to change the current state to one that is better
© 2010 Institute for Healthcare Improvement
IdeasExecution
QIDeveloping Ideas
that will contribute to making
processes and outcome better
Having the capacity and capability to
apply CQI theories, tools and
techniques that enable the
Execution of the ideas
Key Components Self-Assessment
• Will (to change)
• Ideas
• Low Medium High
• Low Medium High
How prepared is your organization?
© 2010 Institute for Healthcare Improvement
• Execution • Low Medium High
"Quality is never an accident; it is always the result of high
intention, sincere effort, intelligent direction and
skillful execution; it
1941, William A. Foster
skillful execution; it represents the wise choice of
many alternatives.”
"If you have a stable system, then there is no use to specify a goal. You will get whatever the system will deliver. A goal beyond the capability of the system will not be reached."
WE Deming – Out of the Crisis.
Collaborating for Quality
NHS Scotland's Quality Improvement Hub
Jane Murkin & Shona Cowan
Context
CONTEXTNHSSCOTLAND’S IMPROVEMENT JOURNEY
Scottish Patient Safety Programme
18 Weeks ServiceRedesign and Transformation
Mental Health Collaborative
Strategic Lean
Long Term ConditionsCollaborative
Diagnostics Collaborative
Planned Care Improvement Programme
Unscheduled Care Collaborative
Redesign and TransformationProgramme
Primary Care Collaborative
Develop the Quality Improvement
Hub, reflecting a new partnership
for improvement between NHS
National Services Scotland (NSS),
NHS Quality improvement Scotland NHS Quality improvement Scotland
(QIS), NHS Heath Scotland, NHS
National Education for Scotland
(NES), and the Scottish Government
Health Directorates Improvement
and Support Team (IST).
Scottish Government, May 2010
The QI Hub aims to bring improvement science into everyday work and language of NHS staff and to support demonstrable improvement in patient care through quality improvement activity. improvement activity.
Building national and local QI capacity and capability
Building on sound foundations
• Global ‘Improvement Movement’ (SPSP)
• Bringing coherence to implementation and improvement support methodology(Healthcare Improvement Scotland/ Quest)Improvement Scotland/ Quest)
• Drawing on NES’ developing educational infrastructure for QI
• Measurement for Improvement (NSS/ISD)
The NHS Scotland Quality Improvement Hub shaped
and developed by NHS boards:
Providing :
1. Implementation support which is flexible and
responsiveresponsive
2. Education and learning about QI which is
Accessible and relevant
3. Measurement of QI which is meaningful
4. Facilitating QI networks for NHS staff
Making it happen....
• Coordinating centre - Elliott House
• Small core team
• QI Hub website development – virtual
communities
Building a Community of Improvement • Building a Community of Improvement
Practitioners (Directory)
• Planned and ‘bespoke’ programmes at macro,
meso, micro levels 1-5
• Board Exec and Improvement Leads
• Hub and spoke model
Creative Space
• A creative and innovative space that enables users to work in an environment conducive to quality improvement
• The space is flexible, • The space is flexible, adaptable, accessible and supportive to make it easy for people to think differently to identify creative and innovative solutions
Implementation Support which is flexible and responsive:
Local• Each board has an infrastructure • Emerging local hubs
National• Supporting NHS boards with the design, testing and implementation • Proof of concept testing to inform next stage
• Think Glucose – prototyping and testing• Think Glucose – prototyping and testing• Building capacity and capability• Person Centeredness, Patient Safety, Older Peoples, Public Health,
Falls, AHP Directors, Out of Hours, Maternity Services, • Advising and supporting boards in relation to coordinating for QI – QI
Mapping• Brokering improvement and topic expertise support• Brokering of design students
The Improvement Journey
EDUCATION AND LEARNING:
QUALITY IMPROVEMENT EDUCATION FRAMEWORK
• Focus on four key staff groups – Foundation, Practitioner, Lead and Board Members
• Identifies knowledge and skills required to be able to
undertake improvement work and links to KSFundertake improvement work and links to KSF• Designed for use by individuals, organisations and
education providers• Quality Improvement Learner Journey will be key - targeted
learning resources will be mapped, where available, and new learning developed to meet gaps
• Opportunity to integrate improvement learning with existing activity
MEASUREMENT:
BUILDING CAPACITY AND INFRASTRUCTURE
• Building capacity in measurement for improvement in information staff
• Leadership in statistical methodology
• Quality improvement data repository to support national improvement programmes
www.qihub.scot.nhs.uk
Quality Improvement Networks
• Great foundations
• Building a community
• Network : Scotland, UK, International
• Network of networks
• What ideas do you have?
• How can we design and co-create?
Quality Improvement Hub Governance Structure
Quality Alliance Board
Partner organisation
boards
Infrastructure
Delivery Group
Delivery Groups
• Safe
• Person centred
• Effective
Operational
Steering Group
Quality
Improvement Hub
Action Group
Strategic
Partnership Group
Hub Web and ICT
Integration Group
Communication
SubgroupOther Subgroups
Action Groups
• Workforce
• Governance
• eHealth
• Quality
Measurement
Framework
Proposal for the
Strategic Partnership
Group to become the
Quality Improvement
Hub Action Group
Embedding a Culture of Embedding a Culture of Continuous Quality Continuous Quality Continuous Quality Continuous Quality
ImprovementImprovement
October 2011
Why we wanted a ‘hub’
• Fragmented initiatives
• Variety of ‘brands’ and ‘terms’ across the organisation
• Opportunity to improve the organisation-wide approach
• Provide ‘meaningful’ support to delivery of services
• Maximising knowledge and skills
Current Development
• Mapping and reviewing current quality improvement activity across the organisation (quality & efficiency)
• Review education provision in context of Quality Improvement Curriculum Framework
• Develop an NHSL Improvement Community
– Integrated improvement toolkits
– Expert tutorials
– Knowledge Bank
Current Development
• Quality Ambitions supported through our organisational values
• Unearth our organisational culture through the use of Appreciative Inquiry
• Improved data management through the development of Dashboard & LanQIP
Communication
• Web Development of integrated approach to Quality information & resources
– National and Local connectivity
• Ensure single language of improvement – translate terms & simplify for use
• Continue to use stories……positive and negative – all provide valuable learning
• Live, Active, ‘GO TO’ Page on the intranet
Within the ‘Hub’
• Short, focused meetings structured to discuss business and learning experiences
• Active, motivated membership – wide ranging • Active, motivated membership – wide ranging membership
• 1st point of reference for the recent Better Together results
Outcomes, Outputs & Progress
How to measure the impact of the Quality Hub?