Learning Session 1 · 2018-07-10 · Learning Session Overview Session 1 Session 2 Session 3 Session 4 Introduction to the collaborative. QI and microsystem fundamentals, Effective

Learning Session 1

MCA Ward Collaborative

Overview of the Ward Collaborative

Time Topic Who

9.00 Icebreaker Nicola/Maria

9.15 Agenda and Overview Steve

9.35 Welcome Becky Joyce & Helen Brown

9.45 Quality Improvement and Microsystem Basics

(Inc. October Sky Video)

Nicola & Jo

10.45 Break

11.00 Story from the Field – Respiratory CHANGE team Jennifer and team

12.00 Effective Meeting Skills Maria

12.15 Lunch

13.00 Getting Started - Understanding your system using

the 5Ps (Including Speed Painting Video)

13.15 5Ps team exercise (using EMS) Maria

14.30 Break

14.45 Process Mapping (including Paper Aeroplane) Steve & Jo

15.45 Involving Patients in improvement Laura

16.00 Planning Time – Next steps Claire

17.00 Close

MCA Ward Collaborative Aims

• To support wards to improve care for the patients they serve by March

• To build quality improvement capability with the staff on those wards

so that quality improvements can be maintained and improvement

becomes continuous during this period.

• To support and develop new MCA coaches working in the ward

environment by buddying them with experienced service improvement

coaches.

• To create an opportunity for wards to learn from each other, share

improvements and good ideas to accelerate the rate of improvement

for patients

Ward Collaborative Teams & Coaches

Team & Wards Faculty Coach MCA Coach

(B5 & B6 NGH) Steve Claire

Gastro

(RH3 & RH4 NGH) Nicola Davlyn

Spinal (Osborn 2) Maria Donna

Spinal (Osborn 3) Kevin Tim

Infectious Diseases

(E1 & E2 RHH) Nick Colin

Orthopaedics (F1 RHH) Jo Laura

Cardiology CCU Paul Aileen

Ward Collaborative Overview

Workbook p15

Learning Session Overview

Session 1 Session 2 Session 3 Session 4

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

Themes and Aim

statements,

Change Ideas and

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Planning multiple

improvements

using driver

diagrams

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

Themes and Aim

statements,

Change Ideas and

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Planning multiple

improvements

using driver

diagrams

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

Themes and Aim

statements,

Change Ideas and

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Planning multiple

improvements

using driver

diagrams

Introduction to the

collaborative.

QI and

microsystem

fundamentals,

Effective meeting

skills,

understanding

your system using

the 5Ps

Process mapping,

Patient

involvement.

Story from the

field. (CHANGE

room).

Progress reports

from all teams,

Feedback and

sharing on the

Themes and Aim

statements,

Change Ideas and

Measurement

basics.,

Story from the

field. (Hadfield 6)

Planning Time

Progress Reports

from all teams,

Psychology for

improvement

Run charts and

Variation,

SDSA and

sustaining

improvement.

Planning Time

Progress Reports

from all teams as

posters and

presented case

studies.

Capacity and

demand basics.

Planning multiple

improvements

using driver

diagrams

Becky Joyce

Helen Brown

Welcome

9.45 – 10:10

Nicola & Jo

What is Quality Improvement?

Key Elements Required for Improvement to

Happen

• Will to do what it takes to change to a new

system

• Ideas on which to base the design of the

new system

• Execution of the ideas

COMPLEXITY

Ford Mustang

1968 2015

Royal Hallamshire Hospital

1968 2014

Age-standardised five-year relative survival rate,

female breast cancer, England and Wales, 1971-2009

1971-1975

1976-1980

1981-1985

1986-1990

1991-1995

1996-1999

2001-2006*

2007-2009*

Period of diagnosis

* England only

Chance of Successful Outcome

Surgery Post-Op

Potential

Actual: Great

Actual: Poor

Health care: Good News / Bad

QUALITY IMPROVEMENT? What is

High Quality care is care that is:

• Safe – no needless deaths

• Effective – no needless pain or suffering

• Patient-Centered – no helplessness in those

served or serving

• Timely – no unwanted waiting

• Efficient – no waste

• Equitable – for all

Quality: The IOM’s Six Aims

Workbook p19

Improvement

The combination of a ‘change’ (improvement)

combined with a ‘method’ (an approach or

specific tools) to attain a superior outcome

Workbook p20

Model I: Bad Apples

Problem

Quality

Frequency

The Simple, Wrong Answer

Somebody

The Cycle of Fear

Increase

Micromanage Kill the

Messenger

Filter the

Information

Model 2: Positive deviance

Model 2: Continuous Improvement

“Every Defect is a Treasure”

Quality

Improvement - The

structure

Assessment - 5Ps

Diagnosis - Change Ideas

Treatment

- PDSA

‘Standardise’

•Objective

•Questions and

predictions (Why)

•The plan – who what

where when

•Do the Plan

•Document problems,

observations

•Begin analysis

of the data

•Complete analysis of

•Compare data to

predictions

•Summarise the

learning

•What changes

are to made now?

•What is the next

PDSA - experimentation • Always start with a specific aim - What are we trying to accomplish?

• How will know if this is an improvement? – Data.

• Small tests of change over a short time

• Debrief frequently

• Communicate results

• Repeated Cycles

• When we meet our aim? –

SDSA = Standardise

The Value of “Failed” Tests

“I did not fail one

thousand times; I found

one thousand ways how

not to make a light bulb.”

Thomas Edison

Workbook p34

Nicola & Jo

Microsystem Basics

Understanding Systems

• What is a “system”?

• How do we define a “system”?

Understanding Systems

• What is a system?

•System = a collection of processes working

together to produce a defined output

“Every system is perfectly designed to

get the results it gets.”

Paul B. Batalden, MD

Co-Founder The Institute for Healthcare Improvement

Founding Director, Center for Leadership and Improvement,

The Dartmouth Institute for Health Policy and Clinical Practice

Founding Director, Healthcare Improvement Leadership Development

Co-Founder Institute for Healthcare Improvement

37 Workbook p30

Processes?

• How is a process different from a “system”?

• Can we brainstorm a series of processes which

make up the “systems” we might encounter in our

improvement work?

Elements of a Process

Suppliers Outcomes

Thing being passed along

Inputs Outputs

Sequence of steps

Microsystems

• 1992 – Quinn – ‘Intelligent Enterprise’

• Studied the ‘best of the best’

• They are organised around the frontline

interface with the customer

• ‘Smallest replicable unit’

Microsystems

• Nelson, Batalden, Godfrey 2000 – 2007

• Looked at the characteristics of high

performing clinical microsystems

• Formulated a curriculum to develop high

performing microsystems

Medicine

“The principal task of the mesosystem is

to enable the work of the microsystems

for the population(s) of patients served.”

Paul Batalden

What is a Clinical Microsystem?

“The Place where Patients,

Families and Clinical Teams

It’s where everything happens

with, for and to the patient

and family.”

High Performing Clinical Microsystems

Information

Technology

Staff • Staff focus

• Education &

Training

• Interdependence

of care team

Patients • Patient Focus

• Community &

Market Focus

Performance • Performance

results

• Process

improvement

Leadership • Leadership

• Organizational

support

Ownership not Buy In

‘If you want to make true and lasting

change, ask the people who do the

work how to go about it’

Daren Anderson, MD

VP/Chief Quality Officer

Community Health Center, Inc.

Team Coaching

Improvement

Science

Microsystem

Improving Microsystems – The Elements

Workbook p22

Team Coaching

Improvement

Science

Microsystem

Workbook p22

Team Coaching

Improvement

Science

Microsystem

Workbook p22

Coaching

It is not telling people what to do.

It is giving them a chance to examine

what they are doing in the light of their

intentions.

Peter Senge,

MIT and Society for Organizational Learning

‘Improvement in health care is

20% technical and 80% human’

Marjorie Godfrey, MS, RN

The Dartmouth Institute For Health Policy and

Clinical Practice

People and Behaviours

Workbook p32

The Team Coaching Model

Transition Phase Reflection,

Celebration & Renew

Pre Phase Getting Ready

Action Phase Art & Science of

Coaching

Godfrey, MM (2012) In Press

Action Phase

Transition Phase

Pre- Phase

Action Phase

Transition Phase

Pre- Phase

Action Phase

Transition Phase

Pre- Phase

Action Phase

Transition Phase

Action

Transition

The Team Coaching Model Over Time

Action

Phase Transition

53 Godfrey, MM

Team Coaching

Improvement

Science

Microsystem

Workbook p22

People vs. System

“80% of the problem is the system

not the people”

W. Edwards Deming

Professor of statistics at New York University (1946–1993)

Author, lecturer, and consultant

Founding Director, Healthcare Improvement Leadership Development

Co-Founder Institute for Healthcare Improvement

Workbook p33

Just like a patient…

To improve a microsystem’s “health” status

An interdisciplinary group:

• Assesses

• Diagnoses

• Treats

• Follows-up

based on improvement science and performance feedback.

Microsystem Improvement

Assessment

Diagnose

Treat -

‘PDSA’ &

‘SDSA’ What is the purpose of this

What do staff think?

What do patients think?

What does the data tell us?

Define the high-level process

Assessment

Diagnose

Treat -

‘PDSA’ &

‘SDSA’

Define themes, Set aims

Deeply understand a process

Explore the reasons for what

we think are the issues

Assessment

Diagnose

Treat -

‘PDSA’ &

‘SDSA’ Plan – Do – Study – Act

Plan a small test of change

Agree balanced measures

Is the change an

improvement?

Quality Improvement -

The structure

Assessment - 5Ps

Diagnosis - Change Ideas

Treatment

- PDSA

‘Standardise’

5P Assessment

Global Aim

Change Ideas

Specific Aim

Measures

Flowchart

Cause & Effect

The Microsystem

Improvement Ramp

Global Aim

5 P Assessment

Global Aim

Change Ideas

Specific Aim

Measures

Dartmouth Microsystem Improvement Curriculum

Workbook p28

10.45 – 11.00

11.00 – 12.00

Jennifer Hill, Debbie Doanne, Jo Myers, Lindsay

Chat show guests:

The Respiratory CHANGE team

12.00 – 12.15

Effective Meeting Skills

Effective meetings

• Conducted in a disciplined manner

• Active participation of all

• Clear action items

• Agenda for the next meeting

• Evaluation of the meeting

• Runs to time and time well spent

Workbook p40

Participant Participant

Participant

Four essential effective meeting roles

Leader

Facilitator

Recorder

Time -

keeper

Participant

Rotate

Workbook p40

Leader

Workbook p41

Timekeeper

Workbook p41

Recorder

Workbook p41

Facilitator

Workbook p41

7 Step meeting process

1. Clarify Aims – what needs to be done –

priorities

2. Assign Meeting Roles

3. Review agenda – how much time, and priority

4. Work through the agenda

5. Review actions captured

6. Set the agenda for next time

7. Evaluate the meeting

Workbook p42

Ground Rules

• Put time in early on to set these

• Agree how you will work with each other

• Put them up in the room you meet in

CHANGE room - Ground Rules

• You all have a valuable viewpoint – there is no hierarchy

• It’s about the system not individuals

• Please don’t interrupt or start a second conversation

• Don’t say it can’t be done!

• If you oppose you must propose

• Participate in the meeting not in the corridor later!

• Mobiles & Blackberry's off - or at least on silent

• Be present on time and stick to time

• Cut off lengthy discussions, assign items to the car park

• Have and follow an agenda

• Assign actions only to those present at the meeting

• Assign meeting roles

Workbook p44

EVALUATION 0 10

What went well? What could be improved?

Next Meeting….

Workbook p46

12.15 – 13.00

13.00 – 13.15

Getting Started - Understanding your system

using the 5Ps

5P Assessment

Global Aim

Change Ideas

Specific Aim

Measures

Flowchart

Cause & Effect

The Microsystem

Improvement Ramp

Global Aim

5 P Assessment

Global Aim

Change Ideas

Specific Aim

Measures

Workbook p28

“To do things differently, we must see

things differently. When we see things

we haven’t noticed before, we can ask

questions we didn't know to ask before.”

John Kelsch, Xerox

Assessment - • We need data to understand the system

Purpose

Workbook p50 -57

Purpose -

• Why does your microsystem exist?

• What is the purpose of your efforts and work?

‘To enable people with CF to live as normal a

life as possible’

To provide high quality care in an

environment that promotes patient

and employee satisfaction.

Patients

• What is the patient age

distribution?

• Where do you patients come

• Where do they go after

interacting with your

microsystem?

• How satisfied are they?

• Do you notice patterns based

on seasons in your patient

volumes and acuity?

• What are the top diagnoses?

Patients - Who is Evie?

A fictional typical falls

patient who is •83 years old• Lives on her own• Widowed 5 years ago

• Broke her wrist in a fall 6 years ago

• This year has started to have dizzy episodes and

has fallen 5 times• Her GP has referred her to the Falls clinic

Professionals

• Who does what and when

in your microsystem?

• Is the right person doing

the right activity at the right

• What do staff think could

be improved?

• What is the level of staff

satisfaction?

What would you want to change in Renal OPD?

0% 20% 40% 60% 80% 100%

Clinical Outcome

Customer Care

Hospital environment - Cleanliness

Hospital environment - Layout

Hospital environment - Furniture

Clinc appointment scheduling

Information available in outpatients

Waiting time for patients

Seeing the appropriate staff member

Time of day clinic held

Room use/allocation

Staff working patterns

Available equipment

% of replies

1 - No change required 2 3 4 5 - Large change required

Processes

• Review the current system using process

mapping

• Identify the ‘Value’ & the ‘Waste’

Patterns

• What patterns exit in your microsystem?

• What is the variation across the day, week,

• How often do you meet to discuss patient care,

safety and quality?

• What are your results and health outcomes?

Clinic VC147B Tuesday 1/11/11

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Patient 7

Patient 8

Patient 9

Patient 10

Patient 11

Patient 12

Patient 13

Patient 14

Patient 15

Patient 16

Patient 17

Patient 18

Patient 19

Patient 20

Patient 21

Patient 22

Patient 23

Patient 24

Patient 25

Patient 26

Patient 27

Patient 28

Patient 29

Patient 30

Patient 31

Patient 32

Patient 33

Patient 34

Patient 35

Patient 36

Patient 37

Patient 38

Patient 39

Patient 40

Example 5Ps - Pulmonary Vascular

Disease Unit - RHH

The 5Ps

Workbook p106

5P Assessment

Global Aim

Change Ideas

Specific Aim

Measures

Flowchart

Cause & Effect

The Microsystem

Improvement Ramp

Global Aim

5 P Assessment

Global Aim

Change Ideas

Specific Aim

Measures

13.15 – 14.30

5Ps team exercise (using EMS)

The 5Ps

Workbook p106

5Ps team exercise – Instructions (50 min)

• In your teams have a go at creating a mock 5P

poster for your ward(s) using:

- mock data pack (on your tables)

- information in your work books on p.50-57

- ideas from the Respiratory team

- your expert knowledge re your specialty!

• Complete the 5Ps collection planning document

as much as you can

• Practice Effective Meeting Skills! (p.40)

5Ps team exercise – Instructions (20 min)

• Review the posters and planning documents

with your colleagues (10 min x 2)

- one person from the team stays at their table

- the rest of the team moves to another table

14.30 – 14.45

Steve & Jo

14.45 – 15.45

Process Mapping

Paper Airplane Factory

• 4 people per factory

• Customers’ orders for 18 airplanes

• Build as many as you can in 5 minutes

• Must be delivered in the same sequence as

ordered

500 grains/30 secs

270 grains/30 secs

170 grains/30 secs

270 grains /30 secs

Bottlenecks

500/30 secs

270/30 secs

170/30 secs

270/30 secs

InputOutput

Using Process

Maps to generate

change ideas

Replace hospital

kitchen assessment

with home visit

Home visit first step

after referral

Home visit screened

out unnecessary

hospital visits Clinic redesign –

patient stays in one

room – combines all

motion into 1 step

Standard paperwork

reduced duplication

and rework on hand

15.45 – 16.00

Involving Patients in improvement

Claire

16.00 – 16.50

Planning Time – Next steps

3 THINGS – 30 MINUTES – GET CREATIVE

• Work out the logistics of your meetings Workbook pg. 3

• Work out how you will get to know your MCA coaches Workbook pg. 109

(Pre-phase)

• Work out how you will communicate with the rest of your ward team

Think about the media you are going to choose …

…what works for one might not work for another

16.50 – 17.00

What's Next !

1. Establish your weekly meetings

2. Start working with your coaches

3. Start collecting your 5Ps

Next Session

Action Meeting!

20th May 2015

A Floor Seminar Room

Hadfield Block, NGH

3 People per team maximum

Prepare an update on your progress

Ward Collaborative Overview

Learning Session 1 · 2018-07-10 · Learning Session Overview Session 1 Session 2 Session 3 Session 4 Introduction to the collaborative. QI and microsystem fundamentals, Effective

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