Supporting NHS Wales to Deliver World Class Healthcare AWSSIC Year Two Learning Session One 21 October 2009.

Supporting NHS Wales to Deliver World Class Healthcare

AWSSIC Year TwoAWSSIC Year TwoLearning Session One Learning Session One

21 October 200921 October 2009

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Carl JamesHead of Performance Management Policy

Development, Waiting Times and Emergency Care Department for Health and Social Services

WAG

Dr Alan WillsonDirector of Research and Development, NLIAH

Joint Director of 1000 Lives Campaign

Intelligent TargetsIntelligent Targets

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Performance Improvement for PatientsPerformance Improvement for Patients

A View from the Top ??• Minister view clear about need to improve quality of

care

• Driven by clinicians and healthcare professionals

• Consensus that more focus /pace required

Current

• The Dark Side ‘Annual Operating Framework’• Nationally set targets• Top down improvement • Quality vs performance vs finance

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It has achieved improvement !

But……

• Not sensible or clinically credible• Improvement targets not owned by all• Single points of complex pathways – not

representative• Perverse incentives• Limited change which are not sustainable

Fact, perceptions and mythsFact, perceptions and myths

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• Self governing organisations• Patient quality at the centre of design and

delivery• Quality focused improvement targets• Across care pathways• Clinically driven and owned

Will.. • Improve outputs, outcomes and patient

experience• Deliver sustainable change in a complex

system

Somewhere over the rainbow ?Somewhere over the rainbow ?

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Quality

• Reduction of waste (delays, defects, over-production, rework)

• Reduction of variation (against evidence base / across services/across Wales)

• Reduction of harm

What we need is a common What we need is a common language ?language ?

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And a common approach !And a common approach !

Intelligent Targets

Objectives• Complete care pathway• Critical success / ‘Wow’ factors• Evidence based• Outcomes measures (effectiveness, safety, experience)

Approach• 4 pilots (cardiac, stroke, unscheduled care, mental health)• National Steering Group supported by 4 core groups• Driven and made up of healthcare professionals, policy leads• Facilitated by NLIAH • Success of stroke collaborative and 1000 Lives Campaign

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Wales stroke audits over 5 yearsWales stroke audits over 5 years

-what is worse?

• Brain scan in 24 hours – 60% to 38%

• OT assessment - 62% to 50%

• Home visit before discharge – 80% to 53%

-what is better?

• Aspirin started – 72% to 76%

• MDT goals agreed – 58% to 70%

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• Improve the reliability of care in Wales

• Raise the standards of care in Wales

What are we actually trying to do?What are we actually trying to do?

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A QuoteA QuoteAlthough clinicians setting targets is the way forward,

how do we re-educate them to move away from end

line inspection to on line inspection? They have grown

up in organisations which review complaints, undertake

audit, reflect on research….which all have their place,

but amazingly with such a captured audience ‘the

patient’ they fail miserably to monitor, measure and

improve quality at the bedside. Can you imagine a

world whereby all staff were involved in quality

questioning….I would predict a stepped change in

complaints!

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The Intelligent Targets ApproachThe Intelligent Targets Approach

• Focus on process of change

• Use expert groups for subject knowledge

• Use model for change as a standard

• Greenhalgh criteria

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Greenhalgh CriteriaGreenhalgh Criteria• It must have clear relative advantage

• It must have compatibility with the user’s values and ways of working

• Complexity must be minimised

• Users will adopt more readily if innovations allow trialability

• There must be observability, that is it must be seen to deliver benefit

• Reinvention is the propensity for local adaptation

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An evidence-based model for An evidence-based model for producing clinical changeproducing clinical change

• The Model for Improvement

• Agreed process changes (care pathways and driver diagrams)

• Outcome and Process measures

• Appropriate Performance Management

• Support for improvement (will/ ideas/ execution)

Tools- data handling, driver diagrams, collaborative learning

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Model for ImprovementModel for Improvement

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An example from another settingAn example from another setting

Acute MI Care in US• Aspirin at discharge • ACEI for LVSD • Beta-blocker at arrival • Beta-blocker at discharge • Door to lytic • Door to PCI • Smoking cessation advice • Composite and all-or-none scores • Survival rate/index• Aspirin at arrival

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Strategies –Level 1Strategies –Level 1

“Intent, vigilance, hard work”

• Standardized protocols

• Feedback

• Training

• Checklists

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Strategies –Level 2

“Redesign the system – don’t rely on checking”

• Decision aids and reminders built into the system

• Automation

• Evidence as the default

• Scheduling

• Connection to habits

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Experience from Year One AWSSIC

• Method makes sense

• Measurement and reliability are new concepts

• Team work is encouraged across pathway

• Connections with management need work

• We are seeing change and so are patients!

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Respecting measurementDomain Examples

Uptake (organisational conditions

Identified management leadIdentified clinical championIntranet sign upData submittedTeams trainedLocal communication strategy in place

Process change (Intelligent Targets)

Bundle complianceUptake of new practice (specific to driver diagram)

Outcome change (consequence of process)

Reduced morbidityReduced mortalityReduced dependencyReduced hospital stay

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Taking this forward

• Stroke as a starter

• Four clinical areas

• Agree driver diagrams

• Design and prove spreadsheet

• Incorporate in Annual Operating Framework 2010/11

• Support learning and implementation

• 5 year rolling programme

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• Improved quality of care for patients• Clinically owned / evidence based

improvement• Sustainable services

A common language ?

• Reduction of waste• Reduction of variation• Reduction of harm

What's in it for us ?What's in it for us ?